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Chakaura^TM Power Your Life!

To Transform, Create and Heal

with Michèle St. Amour

Retreat Application Form

Thank you for your interest in participating our retreat. We do limit the number of participants from 36 to 58. Once we have received this information our Event Director, Jennifer will review it and she will reach out to schedule a time to talk with you.

At that time you will be required to fill out a longer questionnaire, sign waiver, terms and conditions, and then pay the fee.

Thank you,

Chakaura™ Team

Chakaura™ Retreat Application

Name and Date of the Retreat you are applying to participate in? Please add the location of the retreat.(Required)

Name(Required)

First Last

Email(Required)

Cell Phone including country code/area code(Required)

Where are you currently located?(Required)

Your sex at birth?(Required)

Male

Female

Birth Date(Required)

MM slash DD slash YYYY

What is your weight and your height?(Required)

Are you traveling alone?(Required)

Are you able to walk approximately 1km a day?(Required)

Yes

There will be daily walks.

What is your swimming ability?(Required)

I have lifeguard experience

Fairly strong swimmer and I am able to tread water

I can't swim. I just stay in the shallow end of the pool

I don't like to go in the water

Do you have any addictive habits like smoking tobacco products, marijuana, alcoholic beverages more than a few times a week?(Required)

Yes

Occasionally

Are you on any prescription drugs and if yes please describe and for what.(Required)

Do you have any restrictions in terms of mobility or fears that would interfere with our activities?(Required)

Have you received any of the following vaccines in the past?(Required)

Yes

Flu vaccine, Shingles vaccine, mRNA vaccine (Covid-19) such as Pfizer, Moderna, Johnson & Johnson, AstraZeneca, and Boosters.

If yes, please indicate which vaccines you have received and the inoculation dates for each one.(Required)

What are the main reason(s) you wish to participate at this event?(Required)

What are you looking to experience from the upcoming event?(Required)

Please share anything else you feel is pertinent as information shared with us you feel we should know for your Chakaura™ Event.(Required)

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