Mount Madonna Retreat

Women's Winter Re-Set at Mount Madonna Center

January 8 - January 10, 2027
Registration Form

Welcome to your Women's Retreat at Mount Madonna Center! Please fill out the following form. Upon registration and receipt of this form, you will receive a follow up email with more retreat details.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
example@example.com
Birth Date:
xx/xx/xxxx
Roommate Request (if any)
Emergency Contact Information
Name, Relationship & Phone Number
Food Sensitivities or Medical Conditions you would like us to know about:
Please List
What are your hopes for attending this Retreat?
What is your prior experience with Yin Yoga? (if any)
What is your prior experience Meditation?
Payment

A $100 deposit is required to reserve your space. The balance due of $350 will be divided into 2 payments: ($175 due 8/1/26 and $175 due 11/1/26.) You may pay via Venmo, Zelle, or personal check. Venmo: @Roxanna-Smith-2, Zelle: roxanna.smith@gmail.com
Liability Waiver, Terms, and Conditions

Payment and Cancellation Policy: To reserve your space a $100 deposit is required. Cancellations after registration will be refunded at 75%. Cancellations within 90 days prior to retreat will be refunded at 50%. Cancellations within 60 days of retreat are non-refundable. All cancellations must be in writing and sent via email.
Yoga Release

I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all damages, which may incur through participation. I agree to release Roxanna Kopp Smith from any responsibility of loss, damage, or injury that may occur on this retreat.
By checking this box, I state my understanding and agreement with the waiver, terms, and conditions of this contract
Should be Empty:

Women's Winter Re-Set at Mount Madonna Center

Registration Form

Payment

Liability Waiver, Terms, and Conditions

Yoga Release