Contact Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Tell us about you:

Please share with us your intention for the weekend

Please list any food sensitivities, dietary needs, or allergies you may have

Are you currently experiencing any physical ailments, injuries, trauma healing or mental health conditions?

Accommodation Selection

Please select your accommodation preference

If you chose double occupancy, do you have a friend you plan on rooming with of will we be pairing you with another attendee?

Designated roomate if applicable

First Name

Last Name

VIP Solo Immersion

Would you like to add a solo VIP immersion of an energetic balancing and intention setting?

Payment Information

Name on Card

First Name

Last Name

Credit Card Number

Expiration Date

CVV

3-Digit code located on rear of card

Zipcode

Is there anything else you would like us to know?

Somatic Immersion 2024