BALI: Yoga. Surf. Healing Registration

By submitting this form, you will initiate a follow-up email with instructions on how to pay for your admission to the BALI: Yoga. Surf. Healing. retreat! PayPal or Venmo are accepted. The deposit amount is $500 and is non-refundable. This amount not only holds a space for you at the retreat, but locks in your pricing rate. This deposit goes toward your final admission price. SMILE! You’re going to Bali!


Please complete the form below

Full Name *
Full Name
Phone Number (mobile, preferably) *
Phone Number (mobile, preferably)
May we text you at the above number? *
Preferred method of contact? *
Date of Birth *
Date of Birth
Gender *
Dietary Restrictions/Preferences? * Please let us know any dietary restrictions/preferences so we can be sure to accommodate! (Note: Vegetarian Balinese/Indonesian food will be served at the retreat center, but it is in no way restricting you to that diet the entirety of our trip.) If none, write "N/A."
Please describe any medical conditions or injuries that we should be aware of, and give as much detail as you can (i.e. date of injury, whether or not it still bothers you, if it's a continuing condition, etc.) If none, write "N/A."
We are FAMILY! All rooms are double occupancy. Have a request? Let us know, and we'll be sure to do our best to accommodate. (If none, write "N/A")
Website, friend, email etc.
If you heard from a friend or facilitator, let us know!
Anything else we should know? Write it here.