Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Emergency Contact Cell Phone *

(###)

###

####

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you are not performing any physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or a heart condition? *

Yes

No

Do you know of any other reason why you should not engage in physical activity? *

Yes

No

Do you sit for extended periods during the day? *

Yes

No

Do you wear high heels? *

Yes

No

Does your job cause you anxiety or stress? *

Yes

No

Do you experience any chronic pain or have you ever sustained an injury (knee, back, ankles, etc)? *

Yes

No

Have you had surgery? *

Yes

No

Do you have any food allergies or intolerances? *

Yes

No

Do you follow a special diet? (i.e. vegetarian, vegan, pescatarian) *

Yes

No

Would you like us to book you a massage? *

You have the option to purchase a 60 minute massage for $120. We will schedule the massage for you to occur over the course of the weekend. All payments will be made directly to the provider. Massages will take place at the retreat location.

Yes

No