WELLTH Experience Registration Form

Experience WELLTH

April 24 - 29, 2023
Registration & Getting to know you...

Congratulations! You've taking a step toward self-love!
Full Name*

First Name Last Name
Refer to me using my pronouns ex. she/her/hers, them. they, theirs* .
My racial and ethnic identity is/are ex. African American, Afro-Latina, Duwamish*
E-mail*
Enter the same email address you used to reserve your WELLTH Experience.
Phone Number*

Area Code Phone Number
Text Message Option*

Yes, I want to receive WELLTH updates via textNo, I prefer not to receive WELLTH updates via text
Email List Option*

Yes, I want to receive WELLTH updates via emailNo, I prefer not to receive WELLTH updates via email
Date of Birth

MonthDay Year
This is optional: it's being requested to support your travel needs
Food Allergies/Dietary Restrictions:*

I have no food allergiesI have food allergies (list below)I have no dietary restrictionsI have dietary restrictions (list below)
List food allergiesex: nuts, dairy, shellfish, none* . List dietary restrictions ex: Vegetarian, Vegan, Pescatarian, none* .
Health Conditions/ Medications:*

I have no health conditions or physical restrictionsI have health conditions and/or physical restrictions (list below)I take no medications, other than dietary supplementsI take medications (list below)
List health conditions and any physical limitations ex.hypertension, arthritis in knee, none* . List medications ex. Losartan, none* . List accommodation requests ex. first floor bedroom, no stairs, none* . We will make every effort to accommodate your requests. If accommodation is not available, we will contact you immediately.
A note about COVID: The WELLTH Experience will comply with COVID requirements (local and international) for travel to and from Mexico and will take measures to ensure the safety of all guests. Updates will be provided at least two weeks prior to the check-in date. With racial disparities still occurring in the COVID pandemic, centering a low-risk environment for our BIPOC community is paramount.
Employment Status:*

Employed full-timeEmployed part-timeContractor/ Self-employed
Work Title*
Employer/ Business Name*
Employer Information (if registering as Professional Development)

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact Name*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Read and consent to the following WELLTH Retreat Agreement. Print the Agreement for your records.
Signature - I have read and consent to the WELLTH Retreat Agreement.*

Clear
Registration Coordinator: Kimberlee Archie (980) 202-0686 (Leave Message)

Website: www.experienceWELLTH.com

Email: connect@experienceWELLTH.com
Thank you for completing your registration.

You have opened the door to more for yourself and for your community!
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Experience WELLTH

Registration & Getting to know you...

Thank you for completing your registration.