International Retreat Intake Form
2024
Legal Full Name
*
First Name
Last Name
Opportunity Owner ID
Mikayla Ludwig ID
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Passport Number
Passport Country Issued
Passport Expiration Date
-
Month
-
Day
Year
Date
Birthdate
-
Month
-
Day
Year
Date
Cuba Room type
Single ($8,600)
Double ($8,000)
What interested you in this retreat?
Dietary needs
Kindly list down your allergies below:
Amount
Cuba Start Date
/
Month
/
Day
Year
Date
Cuba End Date
/
Month
/
Day
Year
Date
Who would you like to share with:
Would you describe yourself as: a heavy or light sleeper?
*
Heavy sleeper
Light sleeper
Do you snore or talk in your sleep?
*
Yes
No
Maybe
Would you consider yourself:
*
an early riser
a late riser
a night owl
Other
Other:
Is there any additional information we should know when pairing you with a roommate?
Non-refundable deposit to save your spot
prev
next
( X )
USD
Description
Coupon Code
We will invoice you the remaining Balance
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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