Retreat Form

Full name*

First NameLast Name

Birth Date*

DayMonthYear

Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry

E-mail*

example@example.com

Phone Number*

Emergency contact*

First NameLast Name

Emergency contact phone number

Please enter a valid phone number.

Health Details

In order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential.

	Yes	No
Do you have or have you ever had any physical health problems, eg. diabetes, epilepsy, high blood pressure?*
Do you have or have you ever had any mental health problems, eg: anviety, depression, PTSD?*
Are you now taking any prescribed medication?*
Are you now taking any of the following drugs: barbiturates, amphetamines, cocaine, heroin, hallucinogens?*
Do you have muscle or joint problem that could worsen by a change in your physical activity?*
Do you smoke?*

If you answered "Yes" to any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc below

Do you have any dietary requirements/allergies?

Preferred sleeping arrangement

Queen private roomDouble shared roomSingle shared roomPlus partner in queen room

Signature

Date Signed

Date