Costa Rica Retreat Booking Form

My Wellness Retreats - Booking Form
Contact Information

Let us know how to reach you!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attendee Details

Let's get a little more information so we can serve you better during your retreat.
Please provide your License Type/Title if applicable (if you don't have one write N/A)*
Please provide your License Number (if you don't have one write N/A)*
I am registering as a...*

CE AttendeeNon-Attending Guest (must share with a CE-attendee)
Do you have any health limitations or physical injuries that may require accommodations Please indicate if you have any major health issues ex highlow blood pressure arthritis asthma diabetes seizures osteoporosis etc*
Do you have any special dietary requirements*
Please verify that you are human*

Room Selection & Payment

Please select your preferred lodging and pay the deposit below according to the terms.
Please select your preferred lodging*

Single (Private) Occupancy – $3,000 USDShared (Twin) Occupancy – $2,500 USD (shared with another CE attendee)Non-Attending Guest – $2,000 USD (must room with a CE-attendee)
Shared Roommate Name

First NameLast Name
Payment Terms

A $500 USD non-refundable deposit is required to secure your spot. After the deposit is paid, a monthly payment plan will begin the following month. Monthly payments will be calculated based on the remaining balance and the number of months remaining until final payment is due.

Deposit Due Today*

Costa Rica Retreat - Non-Refundable DepositMarch 7, 2026 – March 14, 2026

$500.00 Quantity

Total

$0.00

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

THERAPIST RETREAT PARTICIPATION AGREEMENT

This is a legally binding contract. Please read it carefully.
Signature

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My Wellness Retreats - Booking Form