Registration

Please contact HERE to request your Registration & Health History forms.

After completing them please email or send by post to: Chakra Institute, P.O. Box 34, New Hope, PA 18938

 

Three-Body Purification Retreat: REGISTRATION FORM

Please choose your retreat and price package from the options below.

(All inclusive: Classes, accommodation, room and board)

Dates:

5 Days:$ 200 (Deposit)                       or $ 880

3 Days:$ 200 (Deposit)                      or $ 580 

Arrival time will be 4:00 pm to 6:00 pm and departure time will be 2:00 pm.

PAYMENT INFORMATION

To secure your place a nonrefundable deposit of $200 is required 1 month prior the event.

Please make the check or money order payable to: Chakra Institute  or

Call to pay by credit card: (215) 862-3768 . A 3% charge will be added to this cost, for the service of a credit card.

Please email your completed registration & health forms to: admin@chakrainstitute.com or send by post to: Chakra Institute, P.O. Box 34, New Hope, PA 18938

CONTACT INFORMATION

Gender:

Female _

Male _

Name:

Date of birth:

Email: Phone:

Address:

City:              State / Nation:              Postal Code:                     

PAYMENT INFORMATION

Check or money order enclosed.

 

HEALTH HISTORY FORM

Please list your main health concerns:

Do you have any allergies or sensitivities?

Please list:

Are you taking any supplements or medications?

Please list:

Additional information or special requirements:

(All your information will remain confidential between you and Chakra Institute) Disclaimer: I understand that the purpose of taking the Three Body Purification is to cleanse body, emotions and thoughts. I clearly understand that this Purification is not designed as a cure of any disease. If I have an allergic reaction to any herbs, supplement or foods I will inform the staff and discontinue taking it immediately.

Signature:

Date:

www.chakrainstitute.com | Email: Admin@ChakraInstitute.com | (215) 862-3768 Chakra Institute | non-profit organization