Retreat Registration Form

REGISTRATION FORM
Serenity World Wellness Retreat
"Evolve Your Health & Wellness Journey" Vol.3

We can't wait to see you
on April 1st, 2023 at 9 am!

Pease kindly complete this form to participate in the Evolve Your Health and Wellness Journey Retreat, Vol.3.

Your name

Your Email

Your phone

Gender

Age

Do you have any dietary restrictions/allergies? Please share

Are you now taking any prescribed medication?

Yes

Do you smoke?

Yes

Do you have muscle or joint problem that could worsen by a change in your physical activity?

Yes

Do you have or have you ever had any mental health problems, eg: anxiety, depression, PTSD?

Yes

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

XXL

Your comments and questions:

Please share with us any relevant information or ask questions about the retreat.

I understand that the information I provide is given freely, and will be confidentially stored by Serenity World LLC until further notice. Any information can be withdrawn by a written request sent to serenityworld4you@gmail.com.

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.

+1(919) 737-7292

RETREAT LOCATION:
13219 Boyce Mill Rd,
Durham, NC 27703

Made on

Tilda