The 5R Encounter Retreat Experience
Event Timing: October 4th-7th, 2018
Location: Destin Florida
Contact Us: (912) 257-6248 or hello@5rencounter.info
Website: www.5rencounter.info

This is an investment in helping yourself to grow and shine brighter. It's so worth every penny and every moment to take this extremely precious time out for yourself to reset and connect.

REGISTRATION QUESTIONNAIRE
Please take few minutes to complete the registration questionnaire. By doing so it will help insure that you get the most value out of the Encounter. Please note that your responses are confidential and your privacy will be held in the strictest and highest regard.
What Is Your First & Last Name? *
Your answer
What Is Your Mailing Address? *
Your answer
What Is Your Email Address? We'll use this email to send you retreat information and make sure you receive all of our extra goodies directly in your inbox! *
Your answer
What Is Your Telephone Number? *
Your answer
What Is Your Birth Date? *
MM
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DD
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YYYY
What Is Your Occupation or Profession? *
Your answer
Retreat Preferences
Please indicate your desired preferences below.
Room Preferences *
My Roommates Are:
Your answer
My Meal Preferences *
Do You Have Any Food Allergies? *
If You Answered Yes To The Above Question, Please List Your Food Allergies Below.
Your answer
Personal History
Now for the fun stuff! Let's talk a bit about your personal history and the reason why you will be joining us at the Encounter
What's the most important thing we should know about you right now? *
Your answer
What major life transitions are you going through right now, if any? For example: birth, death, marriage, breakup, job change, recent move, health challenges, etc. *
Your answer
What three things are you most proud of about yourself or your accomplishments? *
Your answer
What’s the hardest thing you’ve had to overcome? Deep breath. We know this can be hard to summarize, but we want to be able to celebrate your strength and resiliency with you. *
Your answer
What are the top 3 most important relationships in your life right now? Please include their names and association with you (For example: partner, children, friend, father, dog, etc.) *
Your answer
What are your three best qualities? *
Your answer
What do you most appreciate about yourself? Go ahead, brag a little or a lot! LOL! *
Your answer
Are you under the care of any physical, mental or allied health professionals? If so, what kind of health care provider are they, and what are they helping you with? Your response is voluntary, confidential and your privacy will be held in the strictest and highest regard. *
Your answer
If you had a magic eraser, what 3 body or health-related challenges or concerns would you erase? *
Your answer
What is your favorite thing about your body? *
Your answer
If you had a magic eraser, what 3 challenges or concerns in your life would you erase? *
Your answer
Which term do you identify with and feel most comfortable using in conversation? *
What brings you joy? Name a few things that make you feel fully alive and connected. *
Your answer
Share with us 1 or 2 goals that you have for your personal and spiritual life. *
Your answer
Share with us 1 or 2 goals that you have for your business, professional or public life. *
Your answer
You're Almost Finished
We’re delighted that you have decided to take such a transformative journey with us. Thank you for taking the first step to an amazing new YOU!
How did you hear about the 5R Encounter ? *
What excites you most about the 5R Encounter retreat experience? *
Your answer
What are 3 things you hope to encounter or walk away with? *
Your answer
You Made It! Yay!
You made it! That's the end of our registration questionnaire. You made the leap! You Jumped! We look forward to meeting you at this life-altering experience.
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