Bali Bellydance & Women's Yoga Retreat Registration Form
Dates: 24th - 30th May 2020
Venue: Ubud, Bali
Contact us at

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 *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Home Address
Your answer
Date of Birth *
Emergency Contact Name & Phone. *
Your answer
Flight Details or Travel arrangements
Your answer
Facebook Profile
This is optional but a good way for us to share photos and group information so highly recommended
Your answer
Accommodation Preference
Tell us a little about your experience with Yoga & Meditation Practices
Your answer
Tell us a little about your experience in Bellydance.
Your answer
What style of Yoga do you prefer?
Power Vinyasa, Yin Yoga, Gentle Yoga, Sacred Women's Yoga, Hatha Yoga etc.
Your answer
Do you suffer from any medical condition? Are you taking any medications?
Your answer
Are you currently experiencing any injuries?
List all that you think are relevant including chronic and acute.
Your answer
What inspired you to join this retreat?
Your answer
What are you hoping to get out of this retreat?
Your answer
Is this your first experience of a Yoga/Bellydance Reteat?
Is this your first time to Bali?
How did you hear about this retreat?
Dietary restrictions *
Anything else you would like us to know *
Your answer
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. *
Thank you so much for filling out this registration form! We looking forward to dancing with you!
With Love, Atira & Lakita
Never submit passwords through Google Forms.
This form was created inside of Atira Tan. Report Abuse - Terms of Service