2024 Renew Her Retreat Application(River Mountain)
We are so excited that you have decided to join us for one of our Graceful Balance Retreats. Please note that this retreat is for WOMEN only, and you must be at least 18 years of age. 
This retreat is designed for counselors and wellness practitioners. 
The date of this retreat is September 12-15.
Location: River Mountain, Everett PA
Sign in to Google to save your progress. Learn more
Name:
Date of Birth
MM
/
DD
/
YYYY
Phone Number: 
Street Address:
Email:
Emergency Contact & Phone number:
How did you hear about Graceful Balance:
What are you hoping to get out of this retreat?
Are you looking for any of the following during this retreat:
What is your greatest challenge at the moment?
Have you participated in any other retreats in the past?
Clear selection
If yes, which ones?
Please select your fitness level:
Clear selection
Please describe your previous fitness experience
What activities of fitness are you currently participating in?
Please list and describe any medical conditions you may have:
Do you experience sleep walking, snoring, insomnia, night terrors or any other sleep disturbance? If so, please provide detail:
Please list and describe any allergies you may have:
Please list your daily medications or as needed medications:
CEUs are currently pending for counselors in MD and PA. If approved, would you need a CEU certificate?
Clear selection
What questions do you need answered before you can commit to this experience?
I understand that the "skylight" and window bunks are assigned on a first come first serve basis in the order of sign ups received.  *
I understand that based upon the order in which my sign up was received that I may be in either the private cabin, or private main lodge room. *
For our group, we have reserved 3 Tents in the Trees. These tents have 2 queen beds inside. Restrooms are located a short walk to the main lodge.  Full linens, comforters, and towels are provided in all Tents in Trees. 

If you choose to stay in a modern tent, you acknowledge that you understand you will need to bring sleeping bags, extra blankets, and warm clothes if you'd like additional heat at night.
 *
If I had a choice, I would prefer: *
I agree that I am a counselor or wellness practitioner *
Required
Please tell us your profession below: *
I have read, understand, and accept the retreat terms and conditions outlined at https://graceful-balance.co/retreat-terms-and-conditions/ *
Photo Release:
PHOTOS, VIDEO, AND CONTENT CREATION
During your participation in a Graceful Balance retreat, it is possible that photos or videos may be taken by fellow participants, guides, and professional photographers. These images and videos may be utilized in various Graceful Balance promotional materials, on our website, and across all social media platforms, such as Instagram, among others, unless Clients explicitly request the photographer or provide written communication to Graceful Balance, indicating their desire not to have their image used in any materials.

By default, permission is granted to Graceful Balance to use these images and videos for publicity and promotional purposes. This permission is perpetual, royalty-free, worldwide, and irrevocable. Graceful Balance values your privacy and will always respect your wishes in this regard. If you have specific preferences regarding the use of images or videos featuring you, please let us know, and we will honor your request accordingly. Your comfort and peace of mind are of utmost importance to us.
 *
I understand that I will be added to the Graceful Balance Retreats email list and communication regarding the retreat will come from Graceful Balance *
Deposit
Deposit price: $500.00 USD.
This deposit is a non-refundable deposit of $500.00 USD. There may be a processing fee incurred dependent on payment selection. This deposit secures your spot for the chosen Retreat. Once this application is completed, you will be emailed an invoice with in 24 hours to pay your non-refundable deposit that MUST BE PAID WITH IN 3 DAYS to secure your spot. After payment, you will be emailed a confirmation and a follow up invoice with the remaining payment amount that must be paid in full 45 days prior to the retreat. Thank you so much!

Total due: $500.00 USD.
Do you have a promotional code? If so, please enter it below:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms