Retreat Registration Form

Guest Information

Name*

First NameLast Name

Email (Please double check spelling)*

example@example.com

Phone Number*

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name

First NameLast Name

Phone Number

Have you practiced Meditation before?

If YES, what type of meditation have you practiced?

Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)

Gender

MaleFemaleOther

Women: Are you pregnant or is there any possibility of being pregnant? If YES, please indicate your due date

Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.

Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)

How did you learn about the Meditation & Integration Retreat?

What inspired you to come to this retreat?

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:

As I participate in activities offered by the hosts and special guests, I understand that the offerings of this retreat are not a substitute for medical attention, therapy, examination, diagnosis, or treatment.

If at any time during the activities, I feel discomfort or pain, I will inform and seek assistance from the teacher.

I may rest at any time during the class and over the weekend. I will listen to my body and respect its limits on any given day.

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any activity program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my participation in meditation classes or yoga workshops.

I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every class.

I accept that neither the instructors, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this retreat.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

My Products

3-Day Retreat

$995.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Meditation & Integration Retreat Registration Form