My Wellness Retreats - Booking Form
Contact Information
Let us know how to reach you!
Name
*
First Name
Last Name
Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attendee Details
Let's get a little more information so we can serve you better during your retreat.
Please provide your License Type/Title if applicable (if you don't have one write N/A)
*
Please provide your License Number (if you don't have one write N/A)
*
I am registering as a...
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CE Attendee
Non-Attending Guest (must share with a CE-attendee)
Do you have any health limitations or physical injuries that may require accommodations Please indicate if you have any major health issues ex highlow blood pressure arthritis asthma diabetes seizures osteoporosis etc
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Do you have any special dietary requirements
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Please verify that you are human
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Room Selection & Payment
Please select your preferred lodging and pay the deposit below according to the terms.
Please select your preferred lodging
*
Single (Private) Occupancy – $3,000 USD
Shared (Twin) Occupancy – $2,500 USD (shared with another CE attendee)
Non-Attending Guest – $2,000 USD (must room with a CE-attendee)
Shared Roommate Name
First Name
Last Name
Payment Terms
A $500 USD non-refundable deposit is required to secure your spot. After the deposit is paid, a monthly payment plan will begin the following month. Monthly payments will be calculated based on the remaining balance and the number of months remaining until final payment is due.
My Products
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Costa Rica Retreat - Non-Refundable Deposit
March 7, 2026 – March 14, 2026
$
500.00
Quantity
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Credit Card
Customer
*
Date
*
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Month
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Day
Year
Date
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THERAPIST RETREAT PARTICIPATION AGREEMENT
This is a legally binding contract. Please read it carefully.
Signature
Today's Date
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Month
-
Day
Year
Date
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