Retreat Registration Form

Retreat Registration Form

Register for The Vilomah Grief Retreat – an immersive experience and supportive space for bereaved parents. Please complete the form below to reserve your place.
Basic Information

Please share your contact details so we can welcome you and stay in touch.
Full Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Retreat Details

Let us know which retreat you are joining and who to contact in case of emergency.
Which retreat are you registering for?*
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Room Selection

Room assignments are confirmed once your deposit is received. To help you select from available options, please note that the retreat website is kept up to date and sold rooms are clearly marked. We recommend checking the website for current availability before choosing your room.
Preferred Room Option*

Private Option 1 - Private KingShared Option 2 - KingShared Option 3 - DoubleShared Option 4 - Bottom BunkShared Option 4 - Trundle bedShared Option 5 - Top BunkOpen Rest Space Option 6 - Day bed
Room selection is confirmed once your deposit is received. We will do our best to honor your preference.
Payment Acknowledgment

Please read and acknowledge the payment process below.
I understand that my spot and room selection are not officially reserved until my deposit is received via Zelle.*

I understand that my spot and room selection are not officially reserved until my deposit is received via Zelle.
Zelle Payment Instructions: After submitting this form, you will receive an email, from Jotform, with the deposit amount and Zelle payment details. Please complete your payment promptly to secure your spot. Details can also be found here.
Care & Considerations

Help us create a comfortable experience for you.
Please list any dietary restrictions or allergies.
Do you have any accessibility needs or accommodations we should be aware of?
Consent & Expectations

Please review and agree to the following to participate in the retreat.
Before agreeing, please take a moment to review our detailed expectations, cancellation, and refund policies here.
The Vilomah Grief Retreat honors the uniqueness of child loss and holds this space specifically for those walking that road. Please confirm:*

I am the parent of a child who has died.
I have read and agree to honor the retreat expectations and participate respectfully.*

I have read and agree to honor the retreat expectations and participate respectfully.
I have read and agree to the cancellation and refund policy.*

I have read and agree to the cancellation and refund policy.
Thank You & Next Steps

We are grateful to welcome you to this retreat.
Thank you for registering. You will receive a confirmation email, from Jotform, with deposit instructions and information about what to expect next. We look forward to being with you.
Should be Empty:

Retreat Registration Form

Basic Information

Retreat Details

Room Selection

Payment Acknowledgment

Care & Considerations

Consent & Expectations

Thank You & Next Steps