Name:

Email Address: (required)

(the system will only accept one email address)

Address or area where you live:

Phone (Mobile):

Additional Home or Work Contact Number (if applicable):

Phone (Home):

Date of Birth:

Gender:
Male
Female

Occupation (optional):

PLEASE TELL US...

Have you been to a Radiance Retreat before?
Yes
No

If so where:

Would type of room would you like?
Twin Share (1 set of Bunk Beds each) - AUD $2,150 (per person)
Twin Share (King Bed & Single Bed) - AUD $2,225 (per person)
Single Room (King Bed & Single Bed) - AUD $2,575
Couple's Room (Queen Bed, own bathroom) - AUD $2,425 ($per person)

Please share your reasons for joining the retreat and what you're hoping to get out of this time on retreat:

Please let us know here if you're new to yoga; a casual or long term practitioner or a yoga teacher; how long you’ve been practicing and what style/s of yoga (if known):

Please let us know if you have any injuries; illnesses, medical conditions, allergies or anything else you think we should know about to ensure you're well cared for:

Detail here any special dietary requests you have; foods you're allergic to or any other food related requests:

Is there anything else we should know about?

Emergency contact name:

Emergency contact number:

Where did you find out about us? Please tick below or fill in the 'other' section:

Word of Mouth / Friend
Jessie's Yoga Books
Radiance Yoga DVDs
Internet Search
Magazine Advertisement (name the publication below, if known)
Facebook
Instagram
Other (please let us know in the box below)

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