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Application to attend the Bali Somatic Yoga Retreat
Somatic Yoga Retreat in Bali, April 10-17, 2026
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Both First and Last Name, Nickname *
Email and Phone Number *
Have you been on a Retreat of any kind before? If so, please share when, where and with who.  *
How did you hear about this Retreat?  *
What are your intentions of joining? What is it that you are needing at this moment, or hoping to get out of it? *
If you feel comfortable to, Please share any medical concerns that may possibly affect your travel, the time abroad or away from your home. This will remain confidential between us. This information will allow me to better support you. *Please keep in mind that an emergency contact will be required for all attendees.  *
How long have you been practicing Yoga (on and OR off the mat)? *
Required
Dietary restrictions *
How is your overall outlook on life right now? And Please share ways you do self-care.  *
An emergency contact, full name, email and phone # *
I understand that we will have to pay $500 deposit to secure my spot and that a payment plan in additional installments is available should I request it. However, the balance is due 120 days before arrival (so by December 10).  *
Required
By filling out this application I have agreed to receive Jacqueline's weekly newsletters. INITIAL below
If you are coming with a friend for a double, please share their name.  *
By hitting submit, I read and understand the cancellation policy: Any cancellations for whatever reason before December 10, 2025 only some of the payments will be recovered (case by case). If After December 10, the full payment is non- refundable. **In either case, IF the spot is filled and the retreat is full THEN You will receive all but $500 refund.  If the RETREAT is Not full, then some of the payment can be recovered as CREDIT for a future retreat with me. At any point after December 10 the deposit is not refunded. INITIAL BELOW  *
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