First name *

Last name *

Phone Number *

Mailing Address *

Please list any dietary restrictions *

Please list an Emergency Contact Name, phone number and relationship to you. *

Do you have any injuries or medical conditions that impact your yoga practice? Please describe *

Please provide a brief description of what you're hoping for in the Meditative Creative Retreat. (This may include requests for practice, meditation, personal goals, or any background to provide the best possible experience for you) *

Would you be interested in adding an optional on-site massage? (Price estimate $150-200)

Photographic release: Do you grant permission to be included in any images, videos or recordings made during the retreat? Do you give permission to use such images, words, and likenesses for marketing, on websites, social media, in brochures, blogs and any other purposes? *

Please read and type your name below to agree to the following consent agreement. I recognize that any form of physical activity is potentially hazardous with risk of possible injury. I hereby affirm that I am voluntarily participating in these activities and agree to expressly assume and accept any and all risks of injury. Likewise, I, my heirs, or legal representative of such forever release, waive, discharge, and covenant not to hold Mariel Little PT, DPT, CYT, or the hosting property Gem Hacienda responsible for any liability. By signing my name in the box, I agree to the above terms.