Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Other health/relational/emotional concerns * *

None

Type 2 diabetes

Type 1 diabetes

Excess weight

High cholesterol

Heart disease

Heart attack

Stroke

Cancer

Thyroid issues

GERD

Constipation

Irritable bowel syndrome

Eczema

Arthritis

Joint pain

Back pain

Osteoporosis

Depression

Anxiety

Cognitive decline

Alzheimers

Marital/relationship conflict

Divorce

Other

Sleep concerns *

None

Sleep apnea

Trouble falling asleep

Trouble staying asleep

Daytime sleepiness

Snoring

Unwanted behaviors during sleep

Other

I understand that reservations are not final until the full amount is paid. You will be contacted via email after your application has been reviewed. *

Yes

I undersand that a basic level of mobility and cognitive ability is required to get the most out of this retreat experience *

Yes

I understand that this retreat does not function as a nursing home, long-term care facility, psychiatric or substance abuse rehab or treatment centre for Covid-19 *

Yes

I understand that photos and vidoes will be taken during the public or group components of the program (e.g. health talks, meals, classes etc). Photos and videos will NOT be taken during therapies, counselling, consults and other private aspects of the program. I understand and accept that photos/videos taken may be used on websites, social media, presentations and other communication channels/media of Paradise Fields and program partners. *

Yes