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    Retreat Date

    Name (required)

    Address (required)

    City (Required)

    Phone (required)

    Email (required)

    Where did you find out about Dragonfly Wellness for Women?

    Date of birth (yyyy-mm-dd)

    What is your Diagnosis and Stage?

    Emergency Contact & Number (required)

    Date of diagnosis (yyyy-mm-dd)

    Dietary allergies: (we will be offering healthy vegetarian meals and snacks with vegan options)

    What are some of your expectations from this wellness weekend retreat?

    Do you have any special health issues or needs that we should know about? Are Stairs an issue for you?

    Do you have any experience with yoga? YESNO

    Complementary treatments are going to be offered on Saturday afternoon. Each session will be 40 minutes. Please indicate whether or not you would like to receive a treatment. YESNO

    Indicate in order of preference the treatments you would like to receive:

    Registered massage

    Reiki treatment

    Mini Facial (organic skin products)

    Caniosacral Treatment

    Thai Yoga Massage

    The group will be staying in both the Edgar House and Fensom Cottage; both facilities are located at Loretto Maryholme. All bedrooms are double rooms with 2 twin beds. If you would like to share a room with someone you know who is also attending the retreat, please indicate below:

    I would like to share a room with: