Retreat Form

Application Form - Rest and Replenish for Mothers

Myall Lakes, May 27-30th, 2022
Full name *

First Name Last Name
Date of birth

Day Month Year
Date
Address *

Street Address

Street Address Line 2

City State

Post Code Country
E-mail *
Phone Number *
Emergency contact *

First Name Last Name
Emergency contact phone number *
Health Details

In order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential.

	Yes	No
Do you have or have you ever had any physical health problems, eg. diabetes, epilepsy, high blood pressure?*
Do you have or have you ever had any mental health issues, eg: anxiety, depression, PTSD?*
Are you now taking any prescribed medication?*
Are you now taking any of the following drugs: barbiturates, amphetamines, cocaine, heroin, hallucinogens?*
Do you have muscle or joint problem that could worsen by a change in your physical activity?*
Do you smoke?*

If you answered "Yes" to any of the questions above, you may like to give further information in relation to frequency, type, amount below. You may also like to include ways we could specifically support you over the duration of the retreat.
Do you have any dietary requirements/allergies?
Preferred sleeping arrangement

Private double room + ensuite Private double room Twin share
I realise that retreats held by Banksia Wellness Retreats require my mental and physical health and I certify that I am fit to undertake it.

I understand there is a $400 non-refundable deposit (unless Covid-19 related, in which case it is refundable. See T &C), and the remainder of my investment is due one month prior to the commencement of the retreat, unless other arrangements have been made with Banksia Wellness Retreats.

Banksia Wellness Retreats

BSB 313140

Acc 12284310
Initials *

Clear
Thank you.

Our partner, Eliza Shumack, will contact you to book your place upon acceptance of your application.
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