What is your full name? *

 
What is your phone number?

 
How did you hear about this workshop?

 
What inspired you to join?

 
What are your dietary requirements? *


 
Emergency contact details *

Please provide: full name, email and phone number.
 
Medical Information *

Please let me know if you have any medical condition or allergy which might require urgent attention or influence your progress or participation during the retreat. You must disclose if you have any mental or neurological condition that might cause mental instability or disruption to normal communication with others.
 
What else would you like to tell me about yourself?

This is a safe and private space, feel free to tell me the things that are important to you and that you would like me to know.
 
Refund & Cancellation Policy *

Refunds will not be given for last minute cancellations. If you cancel before January 6th, you will be issued a refund, minus a $50 processing fee. Refunds will not be issued for cancellations made after January 6th.
     
 
Weekend Workshop Payment {{var_price}} *

The price you will be charged is in USD. This is equivalent to $250 NZD
 
Please enter your Credit or Debit Card number: *

 
The CVC number: *

(3 or 4 digit security number on the back of your card)
 
The name on your card: *

 
Your card's expiry month: *


 
Your card's expiry year: *


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