Retreat Registration Form

Registration Form

Thank you so mush for showing interesting in my Healing retreat in Bali. Please fill out the form carefully for registration.
Name*

First NameLast Name
Email*
example@example.com
Profession*
Where are you based in the world?*
What type of room are you interested in?*

Deluxe Bungalow (Single Room)Suite Bungalow (Shared Room)
Are you currently in a position to invest?*

Yes, I can pay in fullYes, I need a payment planNo, I am not ready to invest
Are you available to have a call with Therese to see if this is a good fit for you?*

Yes!No
How did you hear about this retreat? If from a friend please let me know.
What are your main reasons for joining this retreat?*
Additional Comments
Should be Empty: