Form
Revive & Restore Women’s Wellness Retreat Applicant Questionnaire. (Please answer ALL questions )
Name
*
First Name
Last Name
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Email
*
example@example.com
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Phone Number
*
Please enter a valid phone number.
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Birthdate
*
-
Month
-
Day
Year
Date
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Gender
*
Female
Male
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Why do you want to attend this retreat ?
*
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What are you hoping to gain from this experience ?
*
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This retreat is designed to bring together women with diverse backgrounds and experiences. At Revive & Restore we strive to cultivate a supportive and harmonious environment for all women. By attending, you are committing with us to foster a positive and caring environment for all women attending. Do you agree YES or NO?
*
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Please select your bedroom choice: (all bedrooms are private with 1 bed)
*
Private King Bed - $2900 (ONLY 1 King Bed Left) (single occupancy)
Private Queen Bed - $2600. (single occupancy )
Shared King Bed - $2,500 per person (sharing bed with a friend)
Shared Queen Bed - $2,300 per person (sharing bed with a friend)
Please indicate your preferred payment method:
*
E-Transfer
Credit Card
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If you plan to come with a friend, who will you be sharing with?
*
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Do you have any dietary restrictions or preference?
*
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Do you have any allergies?
*
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How did you hear about us?
*
Anything else you would like us to know?
*
Submit
Should be Empty: