Name *

First Name

Last Name

Date of Birth *

(for age verification)

MM

DD

YYYY

Address *

(Must match your passport)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Gender

Male

Female

Transgender

Gender Neutral

Non-Binary

Pangender

None of your business

Dietary Preferences

Vegetarian

Vegan

Gluten Free

Dairy Free

Other

Do you have any pre-existing medical conditions? *

No

Yes

Have you had any recent surgeries or medical procedures? *

No

Yes

Do you have any allergies? *

(e.g., food, environmental, medication)

No

Yes

Are you pregnant? *

No

Yes

Maybe

How would you describe your current fitness level? *

Excellent

Good

Fair

Poor

Are you comfortable participating in daily yoga and wellness activities? *

Yes

No

Some

Photo and Video Consent *

I understand that during the retreat, Elemental Retreat© may take photographs or videos that could include images of me. I hereby give consent for these media materials to be used for promotional purposes, including the website, social media, and marketing materials.

Yes

No

Please Choose Your Payment Method *

For Our Records

Zelle

Venmo

Revolut

Credit or Debit Card (5% convenience fee is applied)