A Life Changing Immersion into the Sacred Elements Awaits You!

Please take a moment to fill out this form and upon submission you will be redirected to your check out page.

This confidential intake form is intended only for the use of retreat coordinators and facilitators. We request this information to help assure your safety, health, and comfortability.

Thank you for your responses!

I have read and understand all of the details including retreat rates on the retreat page.

Name

First Name

Last Name

Email

Email for any general communication needs.

Phone

Phone Number we can easily reach you at.

(###)

###

####

Address

Please provide your physical address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Date of Birth

Gender

Occupation

Emergency Contact Name

Someone who will not be at the retreat with you.

Emergency Contact Phone Number

Do you have your passport?

Cancellelations made before April 1st will be 75% refundable. Cancellations after April 1st are non-refundable. Thank you for understanding that as soon as payment is received, those funds start being utilized towards the retreat experience.

I have read and understand the cancellation policy

Do you have a friend or partner with whom you will be sharing a bed during the retreat?

If you answered yes, that you will be sharing a bed, please enter their first and last name here.

Use the coupon code SLEEPMATE to redeem your discount for sharing a bed on the check out screen.

Dietary Preferences

Please tell us your dietary preferences/restrictions and if you have any food allergies.

Indicate any known or possible health concerns.

Please note any health-related limitations that might affect your ability to participate in some physical activities.

Describe your experience with any healing modalities, personal development and consciousness exploration.

No Experience Necessary!

What is your Intention for this retreat?

Do you have any specific expectations or benefits that you are seeking from this experience? Write as detailed as you wish.

How did you hear about this Retreat?

Is there anything else that you would like us to know?

A Life Changing Immersion into the Sacred Elements Awaits You!

Questions?

earthandherbsarizona@gmail.com