REGISTRATION FORM
Serenity World Wellness Retreat
"Evolve Your Health & Wellness Journey" Vol.2
We can't wait to see you
on January 28th, 2023 at 9 am!
Pease kindly complete this form to participate in the Evolve Your Health and Wellness Journey Retreat, Vol.2.
Your name
Your Email
Your phone
Gender
Age
Do you have any dietary restrictions/allergies? Please share
Are you now taking any prescribed medication?
Do you smoke?
Do you have muscle or joint problem that could worsen by a change in your physical activity?
Do you have or have you ever had any mental health problems, eg: anxiety, depression, PTSD?
Details to YES answers:
If you answered Yes to any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc. below.
Emergency Contact:
Please provide persons full name and telephone number
Shirt size
Your comments and questions:
Please share with us any relevant information or ask questions about the retreat.
By clicking the button"SEND" you agree to give permission to Serenity World to contact you via the contact information provided regarding upcoming retreat promotions and registration.
Your personal information will NOT be sold, shared, or traded with any third party outside of Serenity World and its affiliates.
Contact us:
+1(919) 737-7292
serenityworld4you@gmail.com
Retreat location:

13219 Boyce Mill Rd,
Durham, NC 27703
Made on
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