Sex
*
Male
Female
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Social Media
(Optional: LinkedIn/ Instagram / Facebook/Website )
How did you learn about this Wellness Vacation?
*
Word of Mouth
Facebook / Instagram
Queen By Nature Wellness
Yogi Antwan
Other
What's inspiring you to take a Wellness Vacay? What do you wish to receive from this experience?
*
Dietary Needs
*
No Restrictions
Gluten-Free
Plant Based / Vegan
Other
Will this be your first out of country experience?
Yes
No
Will this be your first retreat?
Yes
No
In relation to the Digital Detox activity: Will you be able to phone free for a minimum of 8hrs?
*
Yes
No
Other
Yoga Experience ( all levels welcomed):
*
Beginner
Experienced-Beginner
Intermediate-Advanced
Advanced
Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, mental health concerns, etc.)
*
Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.
*
What is your level of comfort when it comes to getting into the water? (pool/ocean/lagoon/river/cenote)
*
What is your level of comfort when it comes to riding a moped/scooter?
*
I'm comfortable
Willing to give it a try
Only will ride if someone else is driving
Nah, not for me, I prefer to be transported in a vehicle at all times.
Room Booking Style Interested in:
*
$2500 - Shared - WOMENS SHARED Guest Bedroom ( 2 Twin Beds\ room shared bathroom )
$3000 - Private - Guest Bedroom Male/Female( 1 King Bed )
$3200 - Private - Master Bedroom Male/Female (larger than guest bedroom - 1 King)
$4800 - Shared - Friend / Couples room. 1 Bed in Canguu / 1or2 bed in Ubud. Private Bathroom ($2400 per person, 2 person in room max)
How would you like to pay for your Wellness Vacay Retreat?
Pay in Full by April 15,2023
$500 Deposit w/ Payment Plan
Affirm Financing
Are you interested in adding on an extra day?
No, it's the perfect amount of days for me.
Day Early - Check in anytime after 3pm May 24,2023
Day Later - Checkout by 11am June 1, 2023
Not sure just yet, but if I'm interested I'll contact you directly.
Is there something that you would like to share about yourself in general?
OPTIONAL
Do you have any Questions, Concerns or Discomforts you would like to share?
What size shirt do you wear?
*
Complimentary Retreat Souvenir Shirt Data
Check your email for all future updates.
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