Fall Cleanse Registration September 18-29, 2021 Fall Cleanse Registration Name Email Phone Address/City/State/Zip Emergency Contact (Name & Phone) Registering for: Ayurvedic Fall Cleanse with Kelley Gardner What are the top 3 reasons you want to participate in the fall cleanse? Are you being treated by a medical professional for any medical conditions? If so, please explain. Do you have allergies or an intolerance to small amounts of dairy in the form of ghee (clarified butter)? Select one No Yes Have you had your gallbladder removed? Select one Yes No Referred By (List only one person, please): Payment: $149.00 Date Paid _____________ Zelle – 704-663-9550 Paypal – PayPal.me/KelleyGardner007 Venmo – @Kelley-Gardner-7 Submit Δ
