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First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

What inspired you to apply for this retreat?

What does “living in rhythm” mean to you right now?

What are you hoping to shift, heal, or activate during this experience?

Do you have any injuries, health conditions, or mobility limitations we should be aware of?

Do you have any food allergies or dietary preferences?

Are you applying for:

Bali Retreat 2025

Other Retreat

Room Preference:

Shared Room (with friend/partner)

Shared Room (pair me with another guest)

Private Room (single occupancy)

Are you attending with someone else?

Yes

No

If yes, who are you attending with?

Are you comfortable participating in (check all that apply):

Daily movement/fitness sessions

Group-based dialogue or reflection

Silent meditation practices

Shared meals and social time

Intentional breathwork or nervous system regulation

How would you describe your current physical activity level?

I move daily and feel strong

I move occasionally but want to do more

I'm just getting started and ready for a reset

I have injuries or limitations (see below)

Please describe injuries or limitations:

Have you ever attended a wellness or transformational retreat before?

Yes

No

I understand that this is a high-integrity, transformational retreat involving physical movement, breathwork, group experiences, and nervous system work.

I Agree

I have questions

I understand the $1,000 deposit is non-refundable, and all cancellation policies apply.

I Agree

I have questions

Is there anything else you’d like to share with us about your journey, intentions, or needs?

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Date

Month

Day

Year

I agree to the Equilibria Community Agreement.

JOIN US AT EQUILIBRIA

START BY FILLING OUT OUR FORM HERE:

KABUPATEN BADUNG REVIVO WELLNESS RESORT