Retreat Sign Up Form

Please complete all of the items on this form (in one session, as your input will not be saved until you submit). Your name and contact information will not be shared. Your information will be kept confidential and reviewed only by Ways of the Rising Woman’s Executive Director, Melissa Sutor, and Retreat Manager, Gina Garcia.

Once you submit this form, you'll have an opportunity to make a donation to Ways of the Rising Woman to support our free counseling programs for women in need.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Racial/Ethnic/Cultural Identifications

Providing the demographic information will help us in evaluating the diversity and impact of our programs and to help us seek funding.

Spiritual/Religious Affiliations

Sexual Orientation

Physical or Mental Disabilities

Providing your health information will allow us to best care for your needs.

Occupation

Household Income

$90,000 or more

$70,000 - $90,000

$50,000 - $70,000

$25,000 - $50,000

$0 - $25,000

How did you hear about this retreat?

State specifically and practically, one goal in participating in this retreat:

Have you been to any kind of retreat before?

Yes

Are you currently seeing a therapist or counselor?

Yes

Do you have a current meditation practice? If so, what type(s) and how often do you meditate?

Do you have previous movement practice/yoga experience? If so, how long and in what style(s)?

What do you want from the movement/yoga classes at this retreat?

Do you have any current injuries, health conditions or chronic pain that may affect your comfort/participation during movement/yoga classes or other retreat activities? If yes, Please explain:

Emergency Contact

Please list an emergency contact person, including their name, phone number, and relationship to you:

Emergency Contact Name

First Name

Last Name

Emergency Contact Name Phone Number

(###)

###

####

Emergency Contact Person Relationship

Anything else you would like to share?

Testimonial—

“They brought together a wonderful group of women and created a space for sharing, opening up, and bonding. The weekend was a perfect blend of yoga, meditation, hiking, and fun expressive activities. Meanwhile, love and humor were the ribbons that tied it all together. Thank you!”

— M.B.

Testimonial—

“Please let me know when you have the next women’s retreat! In the past 10 years, I’ve never felt more peace and de-stressed than when I went to your retreat.”

— S.G.

Retreat Sign Up Form

“They brought together a wonderful group of women and created a space for sharing, opening up, and bonding. The weekend was a perfect blend of yoga, meditation, hiking, and fun expressive activities. Meanwhile, love and humor were the ribbons that tied it all together. Thank you!”

“Please let me know when you have the next women’s retreat! In the past 10 years, I’ve never felt more peace and de-stressed than when I went to your retreat.”

We are going back to our roots while we grow into the new—we are rooted to rise.