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Disconnect to Connect Retreat Application Form
A Nourishing Week of Healing Your Mind, Body, And Spirit through acceptance and compassion Fri Jan 20, 2023 — Thu Jan 26, 2023 Wiltshire, UK
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Your name, please
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First
Last
Date of birth
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Email
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Mobile number (provide country code if outside UK)
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Gender
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Female
Male
Full address
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Are you coming alone?
Yes
No
Who is your room partner, if accompanying:
Do you suffer from any health conditions, injuries or disabilities?
Do you have any allergies:
Tell us about your meditation or yoga experience, if any:
Retreat dates attending
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7 days retreat: 20-26 Jan 2023
Based on the accommodation types available, which one do you require?
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Single room (Sold out!)
2 individuals sharing (Sold out!)
3-4 individuals sharing (same gender) - 1 space left!
2 individuals sharing (male only & no en suite) - 1 space left!
I have a gift voucher
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Yes
No
Inform me if there is one
By which means are you planning to pay? 30% Deposit required to secure your space!
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By bank transfer (will email you account details)
By cash (in one of our locations)
How did you hear about our retreat?
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google search
facebook advert
akanista newsletter
friend recommendation
flyer
other
Anything you'd like to know?
Name
Apply now
