PuckapunyalWellbeingRetreat

Defence Unplugged Retreat 2022

Expression of Interest - Application & Consent Form
Please submit this form as your
EXPRESSION OF INTEREST

Dates and retreat location to be confirmed.

If applying to attend as a couple or members of the same household who wish to share a room, please complete an online application for each person, ensuring that your address is the same for both applications.

Event POC: Deb Herring 0413 805 322
Please select which retreat location you would like to attend in your posting location:

Puckapunyal VICTownsville QLDPerth WATindal NTAdelaide SACanberra ACTOther
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact Name and Contact Number:*
IMPORTANT: Please include best contact number for your Emergency contact
Posted Unit / DVA Reference
Information will be deleted after verification
I will attend as a:*

Overnight guest $79
Your responses to the medical questions will not exclude you from attending the retreat, however, will be used as a guide for retreat activities.

All responses will be treated with strict confidentiality, with the exception of modified exercises or dietary requirements which will be shared with a third party, where appropriate
Are you physically and mentally well? *
If no, please specify further information (ALL DETAILS ARE CONFIDENTIAL)
Can you participate in high intensity activities? *
If no, please specify why
Do you have any medical conditions or injuries?*
If yes, please specify
Do you have any allergies, intolerances or dietary requirement?*
If yes, please specify

Which wellbeing topics interest you?*

	Not Interested	Somewhat Interested	Interested
Goal Setting
Mindfulness
Budgeting
Relaxation
Anxiety
Sleep
Fitness
Managing Change
Confidence
Meditation
Nutrition
Motivation
Burnout
Pilates/Yoga
Zumba

Other topics of interest to you
How did you hear about us?*
Do you agree to be open minded and respectful to all participants at the retreat?*

YesNo
Should be Empty:

Defence Unplugged Retreat 2022