Retreat Registration Form

Which retreat are you registering for?*

Name*

First NameLast Name

Phone Number*

Email *

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are you MOST hoping to gain from a retreat experience? (Choose 3)*

Which retreat activities MOST appeal to you? (Choose 3)*

Please provide a recent photo of yourself.

Please tell me a little about yourself (values, beliefs, work/hobbies) .*

A few sentences or dot points.

Please describe your personality.*

A couple sentences or dot points.

What inspires you and brings you joy?*

A couple sentences or dot points.

What are your three favourite colours?*

Why do you feel inspired to register for this particular retreat?*

A brief sentence.

How many workshops do you ideally want to participate in daily?*

2-33-4

Please outline any health limitations or physical injuries that would impact your participation in the retreat activities.*

Dietary Requirements*

Please outline any allergies or intolerance's.*

What beverages do you like?*

Please identify your sleep patterns and habits so I can pair you with a suitable room mate.*

Early riserLate riserEarly to bedLate to bed

As rooms are shared please indicate if you snore?*

YesNo

If you indicated YES above, please indicate if you use or are you willing to use aids to minimise this impact on your room mate*

YesNoUnsure

If you indicated YES above, please outline how you will minimise this impact on your room mate. (snoring nasal patch, nose guard?)

Please use this space to voice any concerns you may have about your participation at the retreat.*

Is their any additional information it would be beneficial for me to know?*

Emergency Contact*

First NameLast Name

Phone Number*

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:
If at any time during the retreat activities I feel emotionally unsafe or experience physical discomfort or pain, I will inform and seek assistance from the activity facilitator or retreat host. I agree to listen to my body and respect its limits on any given day.

I recognize that it is my responsibility to notify the retreat host of any serious illness or injury that may impact me during the retreat. I accept that neither the instructors, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this retreat and it's associated activities.

I agree to pay a $200 deposit to secure my space for the retreat. This deposit is final with no refunds and I agree that the balance of my payment for the retreat is due by 1st March 2024 (unless agreed otherwise).

I acknowledge that a cancellation fee of $800 will apply if I am unable to attend the retreat, which will cover associated costs incurred.

Exclusion of Participation: In the unfortunate circumstance that a guest conceals physical and/or health issues, and/or causes disruptions or harm that endanger the provision of the services and/or the health and wellbeing of other participants, facilitators, or equipment, the guest can be excluded from participation in the retreat, after an initial warning. If the situation arises, the contract will be terminated without further notice, already paid costs are non-refundable and incurring costs are to be paid by the guest.

I have read the above release and waiver of liability and fully understand it’s contents. I voluntarily agree to the terms and conditions stated above.

Signature

Date Signed

Date

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