Retreat Form

REBOOT. RECHARGE. RELAX.

Nov 30 - Dec 3. Please fill out these questions to attend the retreat.
Full name*

First NameLast Name
Preferred Nickname (if any):

Name
Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
Mobile Phone Number*
Emergency contact*

First NameLast Name
Emergency contact phone number*
Job Title*
Divine Journey Graduate (Resilience Self-love or Mastery):*

YesNo
Instagram Handle:*
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.

Select*

	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: anxiety, 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 problems that could worsen by a change in your physical activity?*
Do you smoke?*

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

Single Occupancy - King or Queen Bed (Private or Single) - $2,600Double Occupany Shared Bed - King or Queen Bed (Shared) - $1,300 per person
Sleeping arrangements are based on availability and are available at a first come first serve basis. Please note: space is limited. Once your selection has been made, you'll receive an email with next steps to secure your spot. If you fail to respond to that email, it will go to the next person in queue.
prevnext( X )
Retreat Deposit$675.00
If you are ready to secure your spot by making your deposit now, please go ahead and set up your payment here. Deposits are not required to submit your application but will be needed to secure your spot. Once you hit submit below it will take you to the payment page.

Quantity

Total $0.00
If you have any questions that you wish to discuss prior to participating in the retreat, please send them to info@miosantana.com.

__________________________________________________________

I realize that retreats led by Divine Journey and its affiliates require my mental and physical health and I certify that I am fit to undertake it.

I understand that all deposits and payments are non-refundable, and the remainder of my investment is due by November 8, 2023.
Initials*

Clear
Thank you.

Our team will contact you to book your place upon acceptance of your application.

*Images are stock images that do not show the actual venue for the retreat.
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REBOOT. RECHARGE. RELAX.