Retreat Form

Application Form - PowerfulME Retreat

BODY RESET - 2025
Name*

First NameLast Name
Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
example@example.com
Phone Number*
Emergency contact*

First NameLast 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.

Type a question*

	Yes	No
Do you have or have you ever had any physical health problems, eg. diabetes, epilepsy, high blood pressure?*
Do you have or have you ever had any mental health problems, eg: anviety, depression, PTSD?*
Are you now taking any prescribed medication?*
Are you now taking any of the following drugs: barbiturates, amphetamines, cocaine, heroin, hallucinogens?*
Do you have muscle or joint problem that could worsen by a change in your physical activity?*
Do you smoke?*
Have you practised fasting in before?*
Have you worked with Coach Michelene before?*

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 requirements/allergies?
I realise that retreats held by PowerfulME Retreats require my mental and physical health and I certify that I am fit to undertake it.
Initials*

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Thank you.

Our CEO, Michelene Adamo, will contact you for a 1:1 on-line meeting to ask you a few questions and to further understand your needs.
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Application Form - PowerfulME Retreat