Light Upon Light - Women's Retreat
Registration Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Do you have a dietary preference or allergies?
*
Any health concerns or special needs?
Please provide an emergency contact and number
*
To help serve you better, tell Amany which feeling(s) you need to work on during the retreat. (Your answer will be kept confidential)
*
Stress
Insomnia
Anxeity
Anger
Grief
Sorrow
Regret
Worries
Loneliness
Shame
Guilt
Low self esteem
Lack of focus
Lack of confidence
Feeling unappreciated
Feeling failure
Feeling stuck
Feeling Bored
Other
I am feeling well, I just want to relax and learn
Other
Sleeping Preference
*
I do not mind sharing a king bed
I prefer not to share a bed
I am not sleeping over
Any comment or questions?
Chose Attending Days and Payment Option
*
Full Retreat ($479
Full Retreat with 6 monthly payments of $83 before November 8
Two Days (197)
Two Days with 2 $100 payments before October 8
One Day ($129)
One Day with 2 $65 payments before October 8
My Products
prev
next
( X )
Full Retreat with a monthly payment
$
547.00
Two Days with Three Meals / Day
You save $30
$
227.00
One Day with Three Meals / Day
$
129.00
Join Through Zoom
Full Retreat / 6 Sessions
$
95.00
Submit
Thank you!
You will shortly receive detailed information and a schedule.
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