Bali Retreat Registration Form

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Gender

MaleFemaleNon Binary

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Email

example@example.com

Passport Number *

Passport Expiration Date*

Date

Upload Passport Copy

Room Type

Single Room $7,997 per personShared Double Room $7,200 per person

Roommate Request

Dietary Needs

Accessibility Needs

Today you will pay a $500 non-refundable deposit to secure your spot. You may choose one of the following payment options for your remaining balance:

Option A: Pay the full balance later (due September 1, 2026)
Option B: Enroll in our 9- month installment plan (automatic monthly charges)

Single Choice (Required): Select Your Payment Plan

Option A: Pay Remaining Balance in Full (due August 1, 2026)Option B: 8- Month Installment Plan

Installment Plan Agreement

Shared Double Room – $7,200 total

Deposit: $500 due at registration (non-refundable).
Remaining Balance: $6,700.
Payment Schedule: 9 monthly installments of $745 each, automatically charged on the 1st of each month from December 1, 2025 through sept 1, 2026.

Single Room – $7,997 total

Deposit: $500 due at registration (non-refundable).
Remaining Balance: $7,497.
Payment Schedule: 9 monthly installments of $833 each, automatically charged on the 1st of each month from December 1, 2025 through Sept 1, 2026.

(Note: final installment may be adjusted by $3 for exact balance.)

By selecting this plan, you agree to automatic monthly payments on the dates listed above. All payments are non-refundable once made.

I agree to the installment option outlined aboveI authorize a monthly automatically charge as outlined above

Payment

Deposit: $500 Make A Payment

Payment in Full Single Room $7997 Make A Payment

Payment in Full Shared Room $ 7200 Make A Payment

Cancellation & Refund Policy

Deposit is non-refundable.
All subsequent payments are non-refundable once made.
Cancellation before April 7, 2026 → deposit may be credited to a future retreat (within 24 months).
Cancellation after April 7, 2026 → no refunds or credits.
If retreat cancelled due to Bali travel restrictions → payments credited toward future retreat within 24 months.
Travel insurance (trip cancellation, medical, evacuation) required; proof due by Sept 1, 2026.

Travel Insurance Requirement

I acknowledge that travel insurance (including trip cancellation, medical coverage, and evacuation) is mandatory for participation in this retreat. I am solely responsible for purchasing and maintaining adequate insurance and will provide proof by September 1, 2026.”

Liability Waiver

I release and hold harmless Essential Journey Wellness (EJW), its owners, employees, agents, and contractors from any liability, claims, or demands for personal injury, illness, property loss, or damages incurred before, during, or after the Bali Retreat (October 4th–14, 2026), except in cases of gross negligence or willful misconduct. I acknowledge that retreat activities may involve physical exertion, emotional processing, and risks inherent in international travel.”

Health & Medical Responsibility

I confirm that I am in good health and fit to participate in retreat activities. I am responsible for disclosing any physical or emotional limitations that may affect my participation. I understand that EJW is not responsible for providing medical care or covering medical expenses during the retreat.”

Payment Terms

I understand my $500 deposit is non-refundable and that all subsequent payments are also non-refundable. I agree to pay the retreat balance in full by sept 1, 2026. Failure to pay may result in cancellation of my registration without refund.”

Conduct & Participation

I agree to respect all local laws, cultural norms, and group guidelines. I understand that disruptive, unsafe, or disrespectful behavior may result in my removal from retreat activities or from the retreat itself without refund. I also understand that schedules, itineraries, and amenities may change due to local circumstances or unforeseen events.”

Photo & Media Release

I consent to being photographed or filmed during the retreat for promotional purposes by EJW. I understand no images will be shared publicly without my prior confirmation, and no group processing sessions will ever be recorded.”

I have read and agree to the Cancellation & Refund PolicyI agree to provide proof of valid travel insuranceI agree to the Liability Waiver.I accept responsibility for my health and medical needs.I agree to the Payment Terms.I agree to the Conduct & Participation Terms.I agree to the Photo & Media Release.