Name *

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Are any of the following relevant to you? *

Epilepsy

High blood pressure not controlled with medication

Extremely low blood pressure

Detached retina

Glaucoma

Cardiovascular disease including but not limited to prior heart attack?

A history of aneurysms in your family

Neurological or brain diseases (including prior strokes and seizures)

Osteoporosis

Asthma

Kidney problems

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I certify that all information provided on this form is true and complete and understand that the admission to the retreat is based on some of the information provided on this form to ensure the safety of all participants. I have read and agree to the general Terms & Conditions (including the Cancellation Policy) and Privacy Policy and understand that my personal data will be processed in accordance with the GDPR.

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