Registration Form

Registration Form
We are so thrilled to have you joining us in celebration of Spring for a day of mindful movement and reflection, wellness workshops, and connecting to the natural rhythm of the season. Please take a moment to fill out this form below so that we can create a beautiful experience for you.
Name*

First NameLast Name
Contact*

Phone NumberEmail Address
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

Name & RelationshipContact Number
How did you hear about us?*
What is your intention for joining this retreat, or do you have an affirmation you'd like to share?*
What is your experience with yoga, breathwork, and/or meditation? *
What are you most looking forward to, or hoping to get out of from this retreat?*
Do you have any dietary restrictions or preferences?*
Please check any boxes that may apply to your current and previous state of health.

Cardiovascular disease (previous heart attack,angina) stroke,Uncontrolled low or high blood pressureRisk of psychosis, bipolar disorder, schizophreniaGlaucoma or retinal detachmentAneurysmsRecent surgery/illnessEpilepsy and/or seizure historyViral or bacterial infectionsCurrent FeverAsthmaPregnancyHiatal herniasDiabetesHistory of surgery or physical injuryPanic attacksSleep apneaTrauma historyPTSDVertigoAny use of recreational or medication that alters brain chemistryAny other medical, physical or psychiatric condition that would impair the ability to integrate physical and emotional release
If you checked any boxes above, please go into further detail below.
Are you experiencing any pain, injuries, or physical limitations?*
What is your current stress level, and what is contributing to it?*
Have you had significant emotional or physical traumas as a child or adult? Please share in whatever capacity you feel safe. *
The facilitators of this event have my permission to use photographs taken from the retreat for future promotion. I understand that the images used may be used on website, social media, and/or printed fliers. I also understand that no royalty, fee, or other compensation shall become payable to me by any reason of such use.*

YesNo
We understand that life can be unpredictable and sometimes plans need to change. To keep things clear and fair for everyone - if you need to cancel, a 50% refund is available for cancellations made on or before March 7th, 2026. Beginning on March 7th, 2026 we won't be able to offer refunds but if something comes up and you can't join us, you're more than welcome to transfer your spot to a friend or loved one at any time.*

Yes, I understand
DISCLAIMER : All guidance, movement, healing, sound, breathwork, and intuitive services are provided for educational and informational purposes only and are not intended to diagnose, treat, cure, or prevent any medical or psychological condition. These services do not replace care from a licensed healthcare provider.You agree it is your responsibility to consult a qualified medical professional regarding any information received during sessions or events.By receiving services from Jaya Sarada, Arielle Beauduy, Andrea Alric, and their affiliates, you release these practitioners and The Luminous Soul Center for Well Being from all liability related to your participation in any session or event.You accept full responsibility for your health, well-being, and outcomes resulting from participation. All participants are required to communicate any discomfort during sessions.By signing below, you confirm that your intake responses are accurate and that you have read and agree to the payment, cancellation, and disclaimer terms above.*

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