Dates: September 23-28, 2025

Location: Peoria, Arizona, USA

Please complete this application so we can get to know you and ensure this retreat is a perfect fit. We'll review your responses and contact you with next steps.

1. Full Name *

2. Age Group (e.g., 50+, 40-49, etc.): *

3. Email Address: *

4. Phone Number (with country code): *

5. City & State / Province: *

6. How did you hear about this retreat? (e.g. social media, friend, newsletter, other) *

7. Intentions & Goals - What inspired you to apply for this retreat? *

8. What are your intentions or goals for attending? What would make this experience truly transformational for you? *

9. Which accommodation are you interested in? *

Option 1: Shared Room ($2,900)

Option 2: Private Room ($3,700)

Option 3: VIP Upgrade (+$497)

10. Do you have any dietary restrictions or food allergies? *

11. Are there any medical conditions, injuries, or mobility concerns we should know about? *

12. Would you like to arrange a payment plan? *

Yes

13. Do you need assistance with travel arrangements (airport shuttle from Phoenix)? *

Yes

14. Emergency Contact Name and Phone Number *

15. Is there anything else you’d like us to know about you or your expectations for this retreat? *

16. Agreement & Consent By submitting this application, I acknowledge that the Reconnect, Reclaim & Renew retreat involves personal growth activities and that I have read and agree to the retreat policies and terms. I understand that submitting this application does not guarantee a spot. A member of the retreat team will follow up with me for confirmation and payment details. Click here to read the Terms and Conditions. https://docs.google.com/document/d/1Y3F5K5igJIWGeM8gNRsKNiOCsyUipGiWUa-rtI6CYI4/edit?usp=sharing *

I Agree

Digital Signature

Clear

Today's Date *