Name *

First Name

Last Name

Phone

(###)

###

####

Emergency Contact - Phone *

Phone number of emergency contact

(###)

###

####

Do you have any dietary requirements? *

Yes

No

Do you have any injuries (past or present) and/or any health conditions that the teachers/hosts should be aware of? *

Yes

No

Waiver *

Please understand that you are responsible for the safe movement of your own body during any wellness activities you participate in. Any known limitations, health issues and/or injuries must be reported on this form and also be considered when participating in any retreat sessions, modifying and adjusting where needed. Please understand that any healing modalities offered at the retreat (e.g., yoga, massage, energy healing, sound healing, meditation and breathwork) are complimentary to any medical treatment. By participating in the retreat you release the teachers/hosts and venue from any liability for injuries or damages arising from my participation, except where such liability cannot be excluded by law.

Yes I agree

T&Cs *

$500 deposit payable via bank transfer to secure your spot. You will receive an email with the bank details after submitting this form. This deposit is fully refundable (minus a small admin fee of $50) up to 31 Jan 2026 - no refunds thereafter. Early bird price available provided the deposit is received by midnight 1 Dec 2025. Payment of all balances due by 1 May 2026.

Yes I agree