WELLNESS RETREAT REGISTRATION FORM Name * First Name Last Name Phone * (###) ### #### Email * Please select which traveling wellness retreat you are interested in? * Arizona - Fall Equinox 9/20/2023 - 9/26/2023 Panama - Winter Solstice 12/17/2023 - 12/23/2023 Are you traveling by yourself or with a group? * Self Group If you are traveling by yourself, would you be open to share a room with someone else attending, for a reduced rate? * Which area of healing are you most interested in learning more about? * Please select ALL that apply. Respiratory Health and Wellness Plant Herbs Ayurveda Medicine Inner Child Diet, Your relationship with food Meditation Yoga Stress Reduction Self-Care Movement and Physical Exercise Spiritual Health, Connection to Nature Relationships What health and wellness topics would you like to see discussed during the retreat? * What specific areas of your health and wellness do you hope to improve during the retreat? * Do you have any dietary restrictions or allergies we should be aware of? Are there any specific activities or excursions you would like to participate in? * On a scale from 1 - 10, how stressful is your life/job/ currently? (10 being most stressful) * On a scale from 1 - 10, how physically active is your lifestyle? (10 being the most active) * On a scale of 1-10, how comfortable are you hiking? (10 being very comfortable) Have you done yoga before? If so, what kind and how long? Do you have any health issues that affect your mobility or are likely to cause you concern when practicing yoga? * The following conditions require specific modifications to your yoga practice. Please tick if any of the following apply to you. If you tick any, please provide further details below. Abdominal disorders Arthritis (osteo/ rheumatoid) Anxiety Back pain/ problems Cancer Depression Heart conditions / disorders High blood pressure Hip problems Low blood pressure/ fainting Knee problems Nerve damage / trauma Osteoporosis Pain, stiffness, swelling Pregnancy / recent pregnancies Broken bones Surgery (in the last two years) Shoulder / neck problems What are your goals and expectations from your retreat? * Is there anything else you would like me to know? Thank you for applying to our retreat! We will review your application and be in touch with you soon.
