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Bali Bellydance & Women's Yoga Retreat Registration Form
Dates: 24th - 30th May 2020
Venue: Ubud, Bali
Contact us at atira@atiratan.com. www.atiratan.com
These questions are simply designed with your wellbeing in mind.
It allows us to gauge how and what pace the retreat is run and specifically what you are looking for when you go away on retreat. In knowing a little bit about YOU we can strive to provide an experience that best serves your needs.
All answers are strictly confidential and will not be shared with anyone else.
Thank you for sharing and taking the time to let us know a bit more about you.
Venue: Ubud, Bali
Contact us at atira@atiratan.com. www.atiratan.com
These questions are simply designed with your wellbeing in mind.
It allows us to gauge how and what pace the retreat is run and specifically what you are looking for when you go away on retreat. In knowing a little bit about YOU we can strive to provide an experience that best serves your needs.
All answers are strictly confidential and will not be shared with anyone else.
Thank you for sharing and taking the time to let us know a bit more about you.
First & Last Name
First & Last Name
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Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Email Address
Email Address
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Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Phone Number
Phone Number
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Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
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Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Home Address
Home Address
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Paragraph
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File upload
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Checkbox grid
Date
Time
Answer key
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Date of Birth
Date of Birth
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File upload
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Checkbox grid
Date
Time
Answer key
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Emergency Contact Name & Phone.
Emergency Contact Name & Phone.
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Short answer
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Dropdown
File upload
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Checkbox grid
Date
Time
Answer key
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Flight Details or Travel arrangements
Flight Details or Travel arrangements
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Short answer
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File upload
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Checkbox grid
Date
Time
Answer key
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Facebook Profile
Facebook Profile
Question Type
Short answer
Paragraph
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File upload
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Rating
Multiple choice grid
Checkbox grid
Date
Time
This is optional but a good way for us to share photos and group information so highly recommended
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Accommodation Preference
Accommodation Preference
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File upload
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Checkbox grid
Date
Time
Single Room
Twin Share
Light Dancer (No Food & Accommodation)
Other:
Add option
…
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Tell us a little about your experience with Yoga & Meditation Practices
Tell us a little about your experience with Yoga & Meditation Practices
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Short answer
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Time
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Tell us a little about your experience in Bellydance.
Tell us a little about your experience in Bellydance.
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Short answer
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File upload
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Date
Time
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What style of Yoga do you prefer?
What style of Yoga do you prefer?
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Checkbox grid
Date
Time
Power Vinyasa, Yin Yoga, Gentle Yoga, Sacred Women's Yoga, Hatha Yoga etc.
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Do you suffer from any medical condition? Are you taking any medications?
Do you suffer from any medical condition? Are you taking any medications?
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Short answer
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Date
Time
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Are you currently experiencing any injuries?
Are you currently experiencing any injuries?
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Date
Time
List all that you think are relevant including chronic and acute.
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What inspired you to join this retreat?
What inspired you to join this retreat?
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What are you hoping to get out of this retreat?
What are you hoping to get out of this retreat?
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Is this your first experience of a Yoga/Bellydance Reteat?
Is this your first experience of a Yoga/Bellydance Reteat?
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Yes
No
Add option
or
add "Other"
…
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(0 points)
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Is this your first time to Bali?
Is this your first time to Bali?
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Short answer
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Date
Time
Yes
No
Add option
or
add "Other"
…
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How did you hear about this retreat?
How did you hear about this retreat?
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Date
Time
Facebook
Instagram
Class
Website
Flyer
Google Search
Other:
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…
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Dietary restrictions
Dietary restrictions
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Date
Time
None
Vegetarian
Vegan
Kosher
Gluten-free
Other:
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…
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Anything else you would like us to know
Anything else you would like us to know
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I have read and understood our retreat terms and conditions, and will be fully responsible for your own health and wellbeing during the retreat. Atira Tan and LAKITA will not be held liable for any injuries or other medical or mental health problems that may occur, are sustained or aggravated during or after your time on retreat.
I have read and understood our retreat terms and conditions, and will be fully responsible for your own health and wellbeing during the retreat. Atira Tan and LAKITA will not be held liable for any injuries or other medical or mental health problems that may occur, are sustained or aggravated during or after your time on retreat.
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Yes. (By ticking this box, you agree to have read our payment and privacy policies).
Add option
or
add "Other"
…
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Thank you so much for filling out this registration form! We looking forward to dancing with you!
Thank you so much for filling out this registration form! We looking forward to dancing with you!
With Love, Atira & Lakita
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