Beautiful Bali 10/10/2026

Beautiful Bali

October 10 - 18, 2026
Registration Form

Please fill out the following form. Once we have received your deposit, you will receive a confirmation email, letting you know that you are registered for the retreat. Space is limited, so reserve now!
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
Emergency Contact Information*
Name, Relationship & Phone Number
Do you have prior Yoga experience?*
What are some of your favorite Yoga practices/postures? Is there any part of the practice (postures, breathing practices, meditation) that you would like to have more of during our time together?*
What are your general goals for this retreat?*

Rest & RelaxGet PamperedPhysical Well BeingPeace of MindFun!Learning About the CultureConnection
Please share any other intentions or goals for this retreat. *
Food Sensitivities or Medical Conditions you would like us to know about:*
Please List
Room/Roommate Request:*
Name of request
Payment

To reserve your space, a nonrefundable $500 deposit is required. Your remaining balance will be divided into two payments. The first payment is due on or before 3/10/26 and the final payment is due on or before 6/10/26. We accept Venmo (@Roxanna-Smith-2) or Zelle (roxanna.smith@gmail.com).
Payment Plans Available

If you would like to set up a payment plan, please contact us. We are happy to work with you. Payment is due in full by August 1, 2026.
Liability Waiver, Terms, and Conditions

Payment and Cancellation Policy: There is a non-refundable $500 registration fee that guarantees your space. Cancellations prior to 120 days of retreat start date will be refunded at 50%, minus the non-refundable deposit payment of $500. Cancellations within 120 days of retreat start date are non-refundable. All cancellations must be in writing and sent via email. There is no refund for any unused portions of the tour, including but not limited to, missed meals, planned outings and scheduled events. Tour rates do not include airfare to Bali. You will need a valid passport to travel to Indonesia.
Insurance and Liability:

Taking any trip can incur delays and changes. That is why we require travel insurance to protect both your investment and yourself. We recommend Squaremouth Travel Insurance: https://www.squaremouth.com Once you have your travel insurance, please email that confirmation to roxanna.smith@gmail.com NOTE: If you purchase travel with a travel credit card your trip may be automatically covered.
Waiver:

I understand this contract and agree to release Roxanna Kopp Smith from any responsibility of loss, damage, or injury that may occur on this trip. I agree to assume all risks associated with this trip including, but not limited to, costs resulting from travel delays, damage to myself and/or my property, or any incidents occurring out of the control of Roxanna Kopp Smith, as well as any activities not associated with Roxanna Kopp Smith. I agree that I must show proof of travel insurance in order to participate in this tour.
By checking this box, I state my understanding and agreement with the waiver, terms, and conditions of this contract*

I agree
Should be Empty:

Beautiful Bali

Registration Form

Payment

Payment Plans Available

Liability Waiver, Terms, and Conditions

Insurance and Liability:

Waiver: