Plateful Productions and Dunia Sante Retreat Reservation Form

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Email *

First and Last Name

Date of Birth

YYYY

Address *

Email Address

Phone Number *

Emergency Contact name and Phone Number

Health Details

In order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential

Do you have or have you ever had any physical health problems, eg. diabetes, epilepsy, high blood pressure?*

Do you have or have you ever had any mental health problems, eg: anviety, depression, PTSD?*

Are you now taking any prescribed medication?*

Are you now taking any of the following drugs: barbiturates, amphetamines, cocaine, heroin, hallucinogens?*

Do you have muscle or joint problem that could worsen by a change in your physical activity?*

Do you smoke?*

If you checked any of the questions above, give details of all occurrences. Include the following: dates, frequency, type, amount etc below
*

Do you have any dietary requirements/allergies?
*

Preferred sleeping arrangement

Queen private room

Double shared room

Single shared room

Plus partner in queen room

If you have any questions that you wish to discuss prior to participating in the retreat, please do so before committing yourself to the program.

I realise that retreats held by Plateful Productions ad Dunia Sante Retreats require my mental and physical health and I certify that I am fit to undertake it.

Type Full Name in Box to sign and agree with the statement.

Send me a copy of my responses.

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