Breathe Retreat 2021- Commitment Form

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This form confirms you intend to attend the 2021 Breathe Retreat and you have read and understood the informational document.

First Name *

Last Name *

E-mail Address *

Home Address (Street number, Street name, Apt #, City, State, Zip code) *

Retreat Date of Choice *

October 15-17, 2021

November 5-7, 2021

Required

How will you be paying for the retreat? *

One time payment of $325 by February 26, 2021

Monthly Payment of $42.86 paid in full by September 10, 2021 ($350 total)

$25- Travelers Insurance (Additional)

Required

T-shirt size? *

XXL

XXXL

Other:

Required

Allergies/Dietary Restrictions?

How will you be traveling to the retreat? *

Would you be interested in car pooling or getting on a shuttle van from Columbus? *

Yes

Maybe

Other:

What do you seek to gain from this experience? *

Additional questions/concerns/comments:

By putting my initials below: *

I confirm all of my previous responses are accurate and in my own words

I understand I must submit a negative COVID test, or confirm I have received the vaccine at least 3 days before arrival

I agree to pay for the retreat according to my selected payment plan above

I understand if I will have a late payment, I will notify the organizer, and I may be subject to a $10 late fee

I understand I may put in a rooming request, but it is not guaranteed

I understand attendance to this retreat will be accepted on a first pay basis. If for any reason I am not accepted and I have paid, I will be promptly refunded.

Required

By putting my initials below, I am committing to show up this weekend with the intentions of coming together with other women to collectively heal. To grow from other attendee's presence and experiences. I will be open to tapping into parts of me that I may have buried or discover a sense of newness within me. I will keep an open mind and come with no expectations. I will leave my judgements of myself and others on the road and will not pick them up on the way home. I understand this is not a retreat where I am allowed to be anything besides my authentic self. I welcome growth, knowledge and healing. I have the heart and desire to share and to help other women release...to breathe. *

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