Booking Form For Tuscany Retreat 2020
* Note: We take data protection very seriously and are always careful and responsible with information entrusted to us as part of your email subscription, booking processes and purchases and we will never share your information. Please view our Privacy Policy on our website – bprior.org
Sign in to Google to save your progress. Learn more
CONTACT DETAILS
Name *
First and Last name please...
email *
Please ensure that you type your email address carefully.
Address *
Mobile Phone *
Home Phone *
EMERGENCY CONTACT
Emergency Contact's Name *
Emergency Contact's Relationship to You *
Emergency Contact's Phone *
ACCOMMODATION
You will book your accommodation directly with the hotel. Details will be sent to you upon receipt of your booking.
For organizational purposes please let us know which accommodation option you will be asking the hotel for.
Room Sharing Option: *
Share With...
IF you know who you would like to share your room with, please list their FULL name(s) below.
DIETARY & HEALTH
Basic Dietary Requirements
Meals on this retreat are buffet style at the hotel with a vast choice of fresh and delicious foods. To the best of their ability (but within reason) they cater for special dietary requirements such as: Gluten Free, Dairy Free & Vegetarian. They may not be able to provide for very strict and limited diets. Please check all that apply.
Allergies
It is essential that you advise the hotel of any allergies. Please let us know here also.
Existing Medical Conditions
Please advise us of any existing medical conditions and medication you are taking.
MENTAL HEALTH
Mental Health Conditions *
Have you ever been diagnosed with a mental health condition (eg. depression, bi-polar disorder, schizophrenia etc...).
Mental Health Condition Details
Have you ever been prescribed medication for a mental health condition? *
Mental health condition previously prescribed medication details (if you answered yes above)
Are you currently taking a prescribed medication for a mental health condition? *
By clicking YES below, you agree that you will remain on this medication for the duration of the retreat.
Current prescribed medication for mental health condition:
Acceptance of Terms & Conditions *
 Click this link for terms & conditions: https://www.bprior.org/terms-conditions
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms