Costa Rica 2026 Registration Form

Costa Rica Retreats/Trainings 2025/2026

Name*

First NameLast Name

Birth Date

MonthDayYear

Gender

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Student E-mail*

Mobile Number*

Area CodePhone Number

Phone Number

Area CodePhone Number

Company

Prerequisite (Only for those doing module 4)*

Other Please Specify

Please list the dates, & the locations of previous modules you have taken.*

If you are registering for modules 1 & 2, put N/A in this box.

Additional Comments

How did you hear about Somatic Exercise Teacher Training?

My Products

Jan 11 - 17 - Private Room - Somatic Healing & Reset Retreat & Module 4$2,488.00

January 11 - 17, 2026 Private room, king bed, private bathroom. 6 Nights, 7 Days, Somatic Retreat/Training, Excursion, Shuttle from San Jose to Casa Firefly, ALL Meals Included.

Color

Jan 11 - 17 - Shared Room - Somatic Healing & Reset Retreat & Module 4$1,888.00

January 11 - 17, 2026 Shared room, shared washroom (with 1 roommate). 6 nights, 7 days, somatic retreat/training, Excursion, Shuttle from San Jose to Casa Firefly, ALL Meals Included.

Color

Enter coupon

Total $0.00

Name of desired roommate

Photograph and Video Release Form

I grant Nikki Semeniuk & Serenity Somatics permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

Photographic, audio or video recordings may be used for the following purposes:

Conference presentations
Websites
Informational presentations
Social Media
Educational videos
By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected, video clips and image, online, and Social Media channels as part of the sessions listed on this document only.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

Signature

Payment Methods

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Registration Form

*NOTE*

NOTE