Medical Form

Congratulations on choosing this transformational

Initiation / Immersion for yourself and those you serve.

Please take a moment to fill in the details below about your medical history.

This is strictly confidential & will only be used in the event of an emergency.

Full Name

Emergency contact name, and their relationship to you

Emergency Contact Phone Inc. Int. code

Are you taking any medication?

Yes

Please elaborate here about your medication(s)..

Have you ever suffered from any of the following?

Seizures

Asthma

Heart Failure Or Stroke

Low Blood Pressure

High blood Pressure

Allergies

Diabetes

Depression

Other

Please elaborate on your answer here.

Dietary Needs

Travel Insurance Policy Number

Travel Insurance Phone Number Including International Code

I certify, warrant and represent that the information provided above is a complete and accurate statement of the physical and psychological conditions that may affect my participation in the this retreat. I agree to take full responsibility for my well being while at the immersion.

I undertake full responsibility to notify should there be any changes in my health status. I have read and agree to the terms and condition of the refund policy.View terms

PLEASE NOTE: During this immersion, we will be partaking in daily yoga, somatic movement, dance, wáter dance, drumming, and a hike to one of Bali’s largest waterfalls. Although EVERYBODY is welcome to join some level of physical & psychological fitness will make the immersion more enjoyable for you!

Terms & Conditions

+62 81237229493