Aligning Chakras Retreat Form

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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, ex: anxiety, depression, PTSD?*
Are you now taking any prescribed medication?*
Do you have an allergy that requires an epi pen, if so do you have one?
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/allergies?

This retreat is designed to take all 7 courses and use the lessons from each one to build on the next, however I understand that may not be possible for everyone. So I need to know which retreats you are interested in attending. Submitting this application saves your spot on the wait list. You will receive an email letting you know if there is a spot for those retreats, and if not your spot on the wait list will be held in case one does open up. I will fill spots with those wanting to attend all 7 first, then fill from first application date on. Once half your payment is received, your spot is reserved.

Let's do them all! I'm in this for the long run!Solar Plexus Oct. 24-26 (self-esteem, relationship with self, digestion, inner critic & inner guide)Heart TBA (unconditional love, compassion, self love, empathy)Throat TBA (speaking your truth, how you communicate or don't communicate with others, words are spells)Third Eye & crown combo TBA (intuition, center for manifesting, trusting yourself, spirituality, connection to source/God and higher self) in MaineThird Eye & crown combo in sedona, AZ

Can we share your image in marketing materials including online and paper flyers?

Please don't include my image in marketing materialsYes, I give permission to use photos that contain my image for marketing use

Before submitting this form be sure to read this section of important information about the retreat. By submitting this form, you are aknowledging you read and except these terms.

The dome has pets that live there full time including dogs. If you have allergies be aware and bring allergy meds or tinctures you may use unless you have a sever allergy. If your allergy is sever we don't reccomend visiting the dome. The retreat will include a lot of time sitting still, as well as a lot of movement at moments, including walking through the woods. You are not required to participate in anything that you are not comfortable with. Just be aware some activities will be outside so prepare accordingly. I try to hold space and provide ceremony for those who need it to heal and grow. In doing this I offer a private space of confidence and free of judgment. We have a what happens in ceremony, stays in ceremony mind set. This being said I ask anything you hear shared at any retreat held by Lunar Peacock Energy Work, you keep private and not share other people's names and stories. You are more than welcome to share your own healing journey, so long as other's privacy is not infringed on. We want all attendees to accomplish as much growth as possible, however no results are ever promised. The results depend a lot on the work done and the effort put in by the individual. Therefore we're not liable if you don't get the results you might be expecting. This retreat is a holistic option to help improve your quality of life, and not medical advice. I am not a medical professional and if you have health issues, you should always seek proffessional medical advice first. This option works great along side other medical advice however. Always check with your doctor before combining natural remedies with medications.

Your spot is not officially reserved until half your payment ($133) is recieved and you recieve your confirmation email. Once your first payment is recieved, the other half must be paid within 10 days of the retreat date. If your payment is not recieved by the 10 day mark, your spot will be offered to someone on the waitlist, and a refund for the half sent will be sent, minus the food fee ($70) because the caterer will already have been paid for your food. The following months after missing a month will be on a first come first serve basis of whoever pays for their spot first.

I will reach out after recieving your application to let you know if there is a spot available for you, and to set up a payment plan. I will accept paypal, venmo, and cash payments to hold your spot.

Pictures will be taken throughout the event for marketing material for future events. If you do not want your image shared in our marketing check the box below and we will either cut you out of pictures or blur the image.

There will be incents and oils burned for aroma therapy at times, to further immerse us into the healing experience. However I understand asthma and other health conditions, may prevent some from using these methods. Will this be a problem for you over the weekend?

Yes, I am sensitive to smellsNo, let the sage and frankincense burn!I can handle it in small amounts in well ventilated areasNo opinion

This application holds your spot on the wait list, payment holds your position at the retreat and your bunk. Let me know what your financial situation is so I know if you are on the active wait list, (payment pending) or if you may qualify for any financial assistance we may receive.

I am in need of financial assistanceI can come up with the money, I just need timeI don't have the money, but want to be on the wait list in case things changeI have the money to reserve my spot ($133) the other half ($133) will be paid within 10 days of the retreat.I'd like to sponsor another attendee

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