Improve Yourself Retreats Booking Form

Retreat Booking Form

Melissa Wilkes, of Improve Yourself will be facilitating this retreat
By attending this retreat you have acknowledged that your needing some changes in your life. Whether that is more relaxation and balance in your life, or you are wanting to restore your mind and body.

This retreat will offer you the time and space for what you, personally, are needing.

By filling out this form, you are allowing Melissa to be prepared and organised, to ensure your best experience.

Your information will remain confidential
Personal Info
Name

First NameLast Name
Preferred Name*
Last*
How did you first hear about our Bali retreats?*

Facebook PostFacebook AdsFacebook GroupInstagramLinkedInGoogle SearchA friend shared it with meOther
Email*
Phone Number*
Date of Birth*

DayMonthYear
Date
Emergency Contact Details (Name, Number, Relationship)*
Secondary Emergency Contact Details (Name, Number, Relationship)*
Address*
Line 2
City
State
Postcode*
Country
Please share details of your travel insurance with Melissa now or minimum 2 weeks before Retreat dates
Relationship Status*
Occupation*
Hours of work per week*
Do you have children & if so what ages?*
If you are registering with someone who will be your roommate, please give their First and Surname name
Please upload a recent photo of yourself (Can be just a head shot)*

Browse Files

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Retreat Choice

Empower Yourself - August 28th - September 2nd 2025
Room Selection

King Bed - Private EnsuiteSingle Bed Twin Share - Private EnsuiteBunk Bed Room Shared with Ensuite
Health Information
Are you affected by any of the following?*

Heart problems of any typeCancer (current or in the past)GlaucomaArthritis, bone or joint problemNeck injuryLow blood pressureHeadaches or migrainesBack injuryAsthmaDiabetesHigh blood pressureLow blood pressureThyroid issuesEye issuesChronic painKnee pain or injuryFoot pain or injuryAutoimmune diseaseBowel issues such as constipation or Diarrhoea
If yes to any of the above, please describe
Do you have any medical conditions not mentioned above? *
Do you take any supplements or medications? Please list*
Will you be bringing these medications to your retreat and ensuring you are taking them each day?*
Do you have any food allergies ? *
Do you currently or have you received any counselling, psychology, or psychiatric services in the past year? If so, please give an outline of the nature of your attendance and therapy. *
Do you have sleep issues that may disturb others, such as snoring or sleep walking?*
Do you have any current injuries. disabilities or physical limitations that may impact on your participation? If so, please clearly state.*
Do you know how to swim?*

I am a confident swimmerI am an average swimmerI am not a confident swimmerI can swim but I prefer not to
Have you had the COVID 19 Vaccination*

1 COVID19 vaccinations2 COVID19 vaccinations3 COVID19 vaccinationsI have not had this
Have you had any reactions or symptoms from the COVID 19 Vaccination OR Virus*

ReactionSicknessNot that I am aware of
What, if any, reactions or sickness have you experienced from COVID19
Rate yourself
How would you rate your overall physical health?*

ExcellentGoodFairPoor
How would you rate your quality of sleep relative to the recommended 7-8 hours per night?*

ExcellentGoodFairPoor
Do you currently exercise? *

YesNo
What best describes the overall amount and intensity of your physical activity during the past three months?
Exercise at least 5x/week for performance or competitive purposesExercise 3 x/week in challenging workoutsParticipate in recreational sports 2-3 x/week, modest effortNo scheduled or structured workouts in place
I eat a balanced diet and feel good about my habits.*

I eat a balanced diet and feel good about my habits.I do okay most of the time, but lose it on the weekends.I know what I need to do, but can't make it happenI don't even know where to start.
What do you do when you are not working (hobbies, sports, etc.)
When you treat yourself, what are things you like to do?*
What part of your life is working well right now?*
What part of your life could be working better?*
What are some obstacles that often keep you from reaching your goals?*
Have you done any personal development work, training, seminars in the past and if so what have you done?*
I am most excited about this retreat because..*
History
Any healers, helpers, or therapies with which you are involved? Please list:*
Do you have any previous retreat experience?*
If YES, can you briefly describe what you have done:
Diet
What sort of foods do you eat now? - Please add your average breakfast, lunch, dinner and snacks*
Do you have cravings? e.g sugar, coffee, drugs, alcohol, medications?*
Do you have any Intolerances (please indicate):*
Are there any foods that you REFUSE to eat or concerns you have while eating in Bali?*
Is there anything else we should know about you?*
The above information is true and correct as of the date of this form and I agree to advise the retreat host, Melissa Wilkes of any changes or discrepancies before attending the retreat.
Name*

First NameLast Name
Signature*

Clear
Payment Plan
Initial $500 Non Refundable Deposit – This is to confirm your stay. Your accommodation and place in the retreat is not locked in until this payment is received

An invoice will be emailed to you for deposit or Full payment.

Once the deposit is made, you will receive a second invoice that will have a remaining balance. This can be paid by one of the payment schedules below until the final payment is due OR you can pay the balance in the next 7 days.
Payment Plan Options – please tick your preferred method
Payment plan

Weekly paymentsFortnightly paymentsMonthly paymentsI will pay the remaining balance in the next 7 days
Whichever payment schedule you choose, you will receive an invoice via email.

You can select on the invoice to set up the payments to automatically be debited from your card, or you can manually pay each time the invoice is emailed to you.

You should contact Melissa if you have missed or know if you are going to miss a payment so you do not lose your place at the Retreat.

Missed payments may result in you losing your place at the retreat and no refunds will be given.
Let me know..
Is there anything else you would like to add?
Media Release Form
From time to time Melissa Wilkes of Improve Yourself would like to share past events with the broader community through media and advertising. Information may be transmitted through various forms including but not limited to magazines, brochures, leaflets, podcasts, websites and other electronic media including social media.
Conditions:
1. From the date that they are taken, photographs, videos, audios and/ or other information provided by you such as testimonials, may be used in Melissa Wilkes and Improve Yourself (business) materials for up to 5 years or until you advise you no longer wish to participate;
2. Photographs and/ or video recordings and/ or audio recordings will be stored with Melissa Wilkes, Improve Yourself premises or in our offsite cloud facility;
3. Melissa Wilkes, Improve Yourself are unable to offer any compensation or fee for its use of your photographs, videos, audios and/ or other information provided by you such as testimonials; and
4. By reading and signing the agreement below, you are acknowledging the intended uses (above) and giving your permission for the photographs, videos, audios and/ or other information provided by you such as testimonials
to be reproduced without limitation by Melissa Wilkes, Improve Yourself. You also agree not to seek payment from Improve Yourself and release Melissa Wilkes from any and all liability associated with the use by Melissa Wilkes, Improve Yourself, of the photographs, videos, audios and/ or other information provided by you such as testimonials as set out in this agreement.
Name*

First NameLast Name
Signature*

Clear
Thank you! Please click SUBMIT
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Retreat Booking Form

Personal Info

Health Information

Rate yourself

History

Diet

The above information is true and correct as of the date of this form and I agree to advise the retreat host, Melissa Wilkes of any changes or discrepancies before attending the retreat.

Payment Plan

Let me know..

Media Release Form

Thank you! Please click SUBMIT