Connection through Creation

Connection through Creation Retreat

With Gina Gee Creative, Bellingen, 3 Nights, 4 Days, April 28-May 1, 2023
Full name*

First Name Last Name
Birth Date*

Day Month Year
Address*

Street Address

Street Address Line 2

Suburb/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, chronic pain?*
Do you have or have you ever had any mental health problems, eg: anviety, depression, PTSD?*
Are you now taking any prescribed medication?*
Do you have muscle or joint problem that could worsen by a change in your physical activity?*

If you answered "Yes" to any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc below
Do you have any dietary preferences/requirements/allergies?
Preferred sleeping arrangement

Double bed in shared room - 1090Single shared room - 980Sharing double bed with a friend (in shared room) - 800
Would you prefer pay in full, or payment plan? (please write OTHER if you'd like to discuss further)
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 that Banksia Wellness Retreats is a safe, inclusive space and welcomes all.

I have read and understood the terms and conditions.

I understand there is a $300 non-refundable deposit, and the remainder of my investment is due by March 1st 2023 (unless other agreement is made with BWR)

Banksia Wellness Retreats

BSB 313140

Acc 12284310
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Thank you.

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