Multiple Sclerosis Study, Physician's Consent / The Expanding Light
14618 Tyler Foote Road
Nevada City, CA 95959
Phone: (800) 346-5350
or (530) 478-7518
Fax: (530) 478-7519

Dear Physician,

We are asking your patient to obtain consent from you to participate in our medical Multiple Sclerosis research project using Ananda Yoga. Ananda Yoga is a gentle style of yoga which uses isometric exercises known as “Energization Exercises”, gentle yoga postures, deep relaxation, breath work and meditation techniques.

The following are the participant requirements:

  • Diagnosed with Multiple Sclerosis and still in the early stages of the disease.
  • Independently ambulatory without assistive devices.
  • Ability to commit to dates of the retreat and follow-up evaluation.
  • Willing to practice at home regularly for 16 weeks.
  • Have not been practicing Energization Exercises regularly for the past year.
  • Signed physician consent form.

If you feel your patient meets all of these requirements, please review and sign the attached physician's consent form. If you have further questions, or would like more information on our study, please do not hesitate to contact us.

Respectfully,

Maitri JonesSuzanne Ilgun

800-346-5350530-478-7509

Please send this form to us in one of these ways:

Mail: The Expanding Light, Attn: Reservations

14618 Tyler Foote Rd

Nevada City, CA 95959

Fax: 530-478-7519

Email:

All responses are confidential.

I, ______(physician's name) do hereby give consent for my patient, ______, to participate in the Ananda Yoga research study on Multiple Sclerosis and Ananda Yoga taking place at The Expanding Light Meditation and Yoga Retreat (hereafter called The Expanding Light). To the best of my knowledge the above named patient will be able to participate in this study without known negative health consequences.

By giving my consent I do not accept any liability or responsibility for the events that happen at The Expanding Light.

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Print name

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SignatureDate

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Address

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City, State, and Zip

Multiple Sclerosis Study
Research Participant Agreement / The Expanding Light
14618 Tyler Foote Road
Nevada City, CA 95959
Phone: (800) 346-5350
or (530) 478-7518
Fax: (530) 478-7519

I , ______, certify that I have been diagnosed with Multiple Sclerosis. As a condition of my participation in the Multiple Sclerosis Research Study, I agree to the following:

  1. I will attend the Research Retreat at The Expanding Light Yoga and Meditation Retreat, January 8 to 13, 2008 and the follow up study on May 9to 11, 2008.
  2. I am able to walk at least 400 feet on somewhat uneven surfaces and climb at least 6 steps independently.
  3. I will practice the techniques I am taught during the Research Retreat regularly at home for 16 weeks between January 13th and May 9th and keep a log of my time spent. I know that free telephone and email support is available to me during this study period and I will contact the research staff if I have questions or need assistance with this practice.

Full Name: / ______
Address: / ______
City, State, Zip: / ______
Phone: / ______
Email: / ______

To reserve your room

Please enclose a $50 deposit by check or credit card.
You can make the check payable to "The Expanding Light."

Circle housing choice:

Standard Shared / Standard Private / Deluxe Shared / Deluxe Private
$175 / $300 / $250 / $400

If You Would Like to Pay by Credit Card

Please fill out this form. We can accept Visa or MasterCard only.

Credit Card #: / ______
Expiration Date: / ______
CVV Security Code*: / ______
Date: / ______
Signature: / ______

*The security code is the last three digits on the back of your card.