BALI -APRIL 2024 Womb Wellness Vacay Registration Form

This is more than just a retreat, your hostess Chandra Aiesha and Theressia Nangle have curated a sacred container for you to breathe deeply in harmony with your vitality through: sisterhood - spa time - restoration - nutritious meals - a digital detox - intentional wellness - adventure and so much more. Most of our activities will be centered around wellness. This will be an authentic experience. There will be a "turn-up" segment as well as a day centered on wellness were we will partake in Herbal Sauna Steam night in addition to a beach day.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Social Media
(Optional: LinkedIn/ Instagram / Facebook/Website )
How did you learn about this Wellness Vacation?*

Word of MouthFacebook / InstagramQueen By Nature WellnessChandra AieshaTheressia NangleOther
What's inspiring you to take a Wellness Vacay? What do you wish to receive from this Wellness experience?*
Dietary*

No RestrictionsGluten-FreePlant Based / VeganOther
Will this be your first out of country experience?

YesNo
Do you need assistance coordinating a flight that aligns?*

YesNoOther
Will this be your first retreat?

YesNo
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,difficulty walking, mental health concerns, etc.)*
What is your experience with Yoga, and/or Meditation?*
Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.*
What is your level of comfort when it comes to getting into the water? (pool/ocean/lagoon/river/waterfall)*
Room Booking Style Interested in:*

$2800 - Shared Room ( 8 days - 4/11 Arrival )$3500 - Private Bedroom ( 8 days - 4/11Arrival )$5200 - 2 Friends sharing a room ($2600/each) (8 days - 4/11Arrival )
How would you like to invest in your Wellness Retreat Experience?

Pay in FullAffirm - Credit Financing OptionHold space with $500 Deposit and make payments (final payment due by April 10,2024)
Is there anything additional that you would like to share about yourself?
OPTIONAL
What size shirt do you wear?
Complimentary Retreat Souvenir Shirt Data
Vibe Check | Phone Call
Wellness Vacay | Ubud Villa Property

Located on a remote location with jungle view, your villa is has been selected to immerse you in the beauty of nature while embracing sustainable living.

Check your email for all future updates.

Wellness Vacay Group photo from our April 2022 Tulum Retreat

#SacralChakraActivate
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