Form

Form

Revive & Restore Women’s Wellness Retreat Applicant Questionnaire. (Please answer ALL questions )
Name*

First NameLast Name

Email*
example@example.com

Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Birthdate *

MonthDayYear
Date

Gender*

FemaleMale

Why do you want to attend this retreat ?*

What are you hoping to gain from this experience ?*

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?*

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-TransferCredit Card

If you plan to come with a friend, who will you be sharing with? *

Do you have any dietary restrictions or preference?*

Do you have any allergies?*

How did you hear about us?*
Anything else you would like us to know?*
Should be Empty: