Apply Form

1. Personal details

Full Name

Date of Birth

Age

Gender

Nationality

Residential Address

Mobile Number

E-mail Address

2. Identity documents

Copy of Aadhaar Card

Copy of Driver's License

Copy of Passport (international participants)

3. Accompanying partner / friend

Name of accompanying person

Relationship

Mobile Number

E-mail Address

4. Emergency contact

Emergency Contact Name

Relationship

Mobile Number

E-mail Address

5. Medical information

Main Health Complaints / Medical History

Blood Group

Known Allergies

Current Medication (name · dosage · reason, one per line)

Other

6. General practitioner (GP)

GP Name

Clinic Name

Mobile Number

E-mail Address

7. Dietary requirements

Please specify

8. Mandatory participant declarations

I confirm that I have carefully read, understood and fully agree with the Somaya Health Terms, Conditions and Liability Waiver. Participation is not possible without acceptance.

I understand that my participation will be confirmed only upon receipt of an advance payment of fifty percent (50%) of the total participation fee payable within three (3) calendar days of registration approval.

I confirm that all information provided in this registration form is complete, accurate and truthful to the best of my knowledge.

I understand that withholding, omitting or providing inaccurate medical information may affect my safety and may result in exclusion from participation.

I consent to participating in the health assessments, diagnostics, screenings, wellness evaluations and educational activities offered during the retreat.

I understand that Somaya Health is educational in nature and does not provide medical treatment, emergency medical care or replacement of advice from my physician or healthcare provider.

I acknowledge that any health recommendations provided during the retreat are educational suggestions and remain my personal responsibility to discuss with my treating physician where appropriate.

I confirm that I am physically capable of participating in light exercise, walking, mobility sessions, yoga, swimming and other wellness-related activities that may be offered during the retreat.

I authorize Somaya Health staff to seek appropriate medical assistance in case of an emergency where I am unable to provide consent myself. Any resulting medical expenses remain my own responsibility.

I understand that Somaya Health reserves the right to refuse or discontinue participation if a medical condition is identified that may endanger myself, other participants or staff members.

9. Photography & Media Consent

Yes, I authorize Somaya Health to use photographs and videos in which I may appear for promotional, educational and marketing purposes. NO, I do not authorize the use of photographs and videos in which I may appear.

Participant Registration
(Goa 24^th–31^stJanuary 2027)

Begin your journey

© 2026 Somaya · Private Health Transformation · Goa

Participant Registration (Goa 24th–31stJanuary 2027)

Begin your journey

Participant Registration
(Goa 24^th–31^stJanuary 2027)