Miriam Peretz Registration Form
Email address *
Retreat/Immersion Name *
Your answer
Retreat/Immersion Dates Attending *
Your answer
Name *
Your answer
Cell phone *
Your answer
Address *
Your answer
Birthdate *
MM
/
DD
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YYYY
Emergency contact Name *
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Emergency contact Number & Address *
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Food Preferences *
Your answer
Food Allergies *
Your answer
Accommodation Preferences *
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Physical Limitations/Injuries *
Your answer
Payment Details
Deposit Payment Amount {note: deposits are non-refundable} *
Your answer
Deposit Payment Date *
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DD
/
YYYY
Balance owed *
Your answer
Balance Payment Date *
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DD
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YYYY
Discounts Applied *
Your answer
Dance Background/Training
Your answer
What do you hope to get out of this retreat/immersion? What are your expectations?
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Disclaimer
All sales are final. There are no refunds on payments, however you can transfer your spot to someone else. Kindly keep us informed on your transfer plan.
I agree to the following statement above. Please fill in your name. *
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