Register for Pura Vida Pilates: Costa Rica

First name

Last name

Email

Phone

Address

Birthday

Month

Day

Year

Room Occupancy:

Single (you have your own room)- $1683 total

Double (you share a room)- $1384 total

If you chose double occupancy, do you have a roommate request?

Do you have any dietary restrictions?

Do you have any medical conditions I should be aware of?

If you selected other, how did you hear about the retreat?

Emergency Contact Name

Relationship to Emergency Contact

Emergency Contact Phone Number

I have read and agreed to the Liability Waiver & Release.

I have read and agreed to the Cancellation Policy.

My signature indicates that I have read, understand, and agree to the Liability Waiver & Release. I have read, understand, and agree to the Cancellation Policy.

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Date of Waiver Signature

Payment

Single Occupancy Full Payment$1,683

Double Occupancy Full Payment$1,384

Single Occupancy Deposit (pay the rest by 5/11) $500

Double Occupancy Deposit (pay the rest by 5/11)$500

Lynbrook Pilates

Register for Pura Vida Pilates: Costa Rica

LynbrookPilates@gmail.com