Self-Compassion Retreat Registration
Thank you so much for your request. Please fill up the following survey and we will contact you as soon as possible.

Please know that all information is treated in the strictest confidence. If you need any clarification please contact us on +66 (0)84 386 0250 or send us an email to villadulac2020@gmail.com
Sign in to Google to save your progress. Learn more
Email *
Full Name: *
Date of birth: *
Telephone number: *
Occupation (s):
If you are sharing a room: Name of the participant you are sharing the room with. *
If you are sharing a room with a friend, please ask her/him to fill in a form and indicate below her/his name.
Do you need transportation from Bangkok to Villa du Lac? *
Do you need transportation from Villa du Lac to Bangkok? *
If you have any medical conditions that we should be aware of please  indicate them here or state "none". *
All information is treated in the strictest confidence. It is your responsibility to inform us of any physical or mental health issue which you may have or any injury recent or past. Also, let us know if you are pregnant. Please update Lotta or Siri on arrival if applicable.
 If you are on any medication that may affect how you feel during the retreat, please provide details. *
Are there any stressful life circumstances that might make this program difficult for you at this time (e.g. a recent loss of a loved one or job, life situation, depression, substance use, fasting) *
Please let us know if you have any food allergy or intolerance or state "none": *
Are you: *
Please let us know if you have any animal allergy ( cat, dog, bee...) or state "none": *
Any other information about your diet that The Villa Chef should know about it? *
Is there anything that might be helpful for the retreat facilitators (Siri & Lotta) to know at this time? *
How did you hear about this retreat? *
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