Retreat Form

Retreat Form
Full name*

First NameLast Name
Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
example@example.com
Phone Number*
Emergency contact*

First NameLast Name
Emergency contact phone number
Please enter a valid phone number.
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.

	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: anviety, 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 problem that could worsen by a change in your physical activity?*

Do you have any dietary requirements/allergies?
Preferred sleeping arrangement

Queen private single room 3600 CADSingle shared room (min 2 ppl) 5800CAD
Will you have your own partner for shared accomodation or would you like us to partner you?

I have a partnerI’m open to being paired up
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