Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address of Emergency Contact *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Emergency Contact *

(###)

###

####

Have you booked your airfare yet? *

Yes

No

Arrival Date

MM

DD

YYYY

Arrival Time

Hour

Minute

Second

AM PM

Departure Date

MM

DD

YYYY

Departure Time

Hour

Minute

Second

AM PM

Add On Services

Please checkbox each service you would like to add-on to your retreat package.

Spa Services (massage, wraps, nails, scrubs, facials - prives vary)

Floating breakfast in salt water infinity pool $25

30 min Reiki Session $65

45 min Personal Readings $60

90 min healing session $170