Retreat Registration

Thank you for your interest in my breathwork retreats!

Please fill out the form below and make a payment to reserve your spot.

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Breath of Freedom Retreat

Registration Form

Which retreat are you registering for?

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Birthday

Month

Day

Year

What are your primary intentions in participating in this retreat?

What are you most excited about learning at the retreat?

Are you ready and willing to be open-minded, welcoming, engaged, and interactive at this retreat?

Yes!

No...

Have you ever been subjected to trauma or traumatic experiences?

Are you currently taking any medications? If so, please list the frequency and dosage below.

In accordance with HIPAA regulations, this information will be kept confidential and not shared with any other individuals or organizations.

Do you currently have any of the following health issues?

In accordance with HIPAA regulations, this information will be kept confidential and not shared with any other individuals or organizations.

If you checked any of the boxes in the previous question, please explain your situation in detail.

In accordance with HIPAA regulations, this information will be kept confidential and not shared with any other individuals or organizations.

It's important to show others what these retreats are all about. We'll be documenting moments at the retreat to share on our website, Instagram, Facebook, and other channels. Are you OK with being photographed/filmed for this purpose?

Yes

No

This retreat payment is non-refundable, as each retreat is uniquely created for its participants. If you are unable to attend this retreat, your payment is not refundable, but can be applied to a future retreat. Click YES if you agree and understand.

Yes

On behalf of myself, my agents, heirs, and next of kin, I hereby release and hold harmless my facilitator and their respective agents, employees, next of kin, and representatives from any responsibility or liability for personal injury, death, or damage to or loss of property that I may incur while I am participating in this event

Click YES to agree to these terms.

Yes

Type or draw your full name and today's date to complete this form.

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Please click the Submit button below to submit your registration. I'll be in touch soon to take your $500 deposit. Thank you!