HEART's REBIRTH RETREAT

HEART's REBIRTH RETREAT - MEXICO

40 mins to Mexico city from 1-7th February 2025 - Visit ahleph.com for more information
How did you hear about us?
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Booking Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emercy Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your motivation behind joining this retreat?*
Tell us about yourself

Health DetailsIn order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential.

Please answer the health related questions below

Rows	Yes	No
Do you have or have you ever had any physical health problems, eg. diabetes, epilepsy, high blood pressure and cardiovascular?*
Do you have or have you ever had severe any mental health problems, eg: bipolar disporder, psychosis, Schizophrenia, 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 smoke?*

If you answered "Yes" to any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc below
Do you have any dietary requirements?
* We only serve plant based , GF meals prepared by our in house chef. This retreat is strictly meat and alcohol free. We kindly ask all participants to respect our space and avoid bringing or consuming any animal product, alcohol to the retreat.
Have you attended KAP (Kundalini Activation Process) class in the past ? Please specify how many classes and name of the KAP facilitator*

Hearts Rebirth Retreat - Mexico

Twin shared bedroom (limited New Years Offer ends 31st December) ($1990 per person)

$1,990.00 Quantity

Total

Credit Card

Apple Pay

HEART's REBIRTH RETREAT - MEXICO