Retreat Application Form BYRON BAY: 29 october - 1 November 2020 Step 1 of 2 50% Name* First Last Date of Birth DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Best Contact Phone Number*Emergency Contact DetailsName* First Last Contact Number*(Optional)Food and AccommodationDietary Requirements (feel free to select more than one)* Gluten Free Vegetarian Vegan Pescatarian None Food allergy (please specify) Preferred accommodation* Standard room (shared bathroom with one other) Twin share with ensuite Single room with ensuite Note: retreat participants must stay onsite. It is not possible to stay elsewhere and attend during the day.If you have chosen twin share, please provide the name of the person you would like to share with so that we can manage our room bookings. If you have chosen a single room but would like to be in the same house as a friend, please provide the name of the person you would like to share the cottage with. We will do our best to accommodate but can make no guarantees!Would you like to schedule a massage during the course of the weekend (at your own expense)? Yes No Numbers required for scheduling purposes. Payment to be made direct to massage therapist at the time of your treatment.(Health fund rebates available) For me to assess your suitability or the program, please answer the following as best as you can. This information is entirely confidential, and responses will not preclude you from attending but will help me to tailor the retreat for individual needs.Do you have any current or recent history of mental health issues (e.g., depression, anxiety, PTSD, alcohol or substance misuse)? If so, please briefly outline.*Your response will not preclude you from attending but I may need to book a call with you to confirm your suitability for the retreat.Do you have any experience of meditation? (note: this is not a meditation retreat but there will be some exercises involving meditation)*Do you understand that a $295 deposit needs to be paid within 3 days?* Yes, I understand and submit my application *Deposit to be paid preferably at time of application or as soon as possible thereafter. If the retreat is fully booked or your application not accepted, deposit will be refunded in full.After you pay your deposit, you will be invoiced for the remaining amount. Please choose how you wish to be invoiced:* Full Amount (early bird due 15th November, 2019) Payment Plan (Full price - 3 x instalments with total due by 4th January, 2020) Δ
