My Wellness Retreats - Selva Terra, Panama Booking Form
July 19, 2026 – July 24, 2026 | Up to 15 CE Credits Available
Contact Information
Let us know how to reach you!
Name
*
First Name
Last Name
Email
*
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...
*
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
*
Do you have any special dietary requirements
*
Please verify that you are human
*
Back
Next
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 – $3,500 USD
Shared (Twin) Occupancy – $2,750 USD (shared with another CE attendee)
The Beach House - $2,500 USD (Has 2 beds downstairs and 4 beds upstairs)
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.
Deposit Due Today
*
prev
next
( X )
Panama Retreat - Non-Refundable Deposit
July 19, 2026 – July 24, 2026
$
500.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
ACH Bank Transfer
Customer
*
Date
*
-
Month
-
Day
Year
Date
Back
Next
THERAPIST RETREAT PARTICIPATION AGREEMENT
This is a legally binding contract. Please read it carefully.
Signature
Today's Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: