Sedona Retreat 2021 To hold your spot we must have this completed form and payment of your $2840 non-refundable fee. Email Name Full Legal name to be printed on your Soul Body Fusion Certificate First Middle Last NicknameIf preferred BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City State / Province / Region ZIP / Postal Code Mobile Phone*Name of RoommateIf applicable TransportationWill you have a car? Dietary PreferencesIf any, please describe Covid Vaccination Yes No Arrival Date / Time Departure Date / Time I am currently certified as a Soul Body Fusion Practitioner Yes No Emergency Contact Name* Emergency Contact Phone Number* Payment option chosen Check has been mailed Paypal Credit Card Consent*I take full responsibility for my health and well-being during the Retreat. I understand that the Retreat includes outdoor activities such as hiking and climbing and agree to hold harmless Jonette Crowley and the Center for Creative Consciousness for any injury, sickness or accident that may occur during our time together. I agree to the indemnification policy.Printed Name* First Last Date SignedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
