Bali Healing Retreat Booking Form Desired Retreat Start Date Is your start date flexible? YesNo Personal Info NationalityAmericanAfghanAlbanianAlgerianAmerican SamoanAndorranAngolanAnguillanAntarcticAntiguan And BarbudanArgentineArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBissau-GuineanBolivianBosnian And HerzegovinianBouvet IslanderBrazilianBritishBritish Indian Ocean TerritoryBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCaymanianCentral AfricanChadianChileanChineseChristmas IslanderCocos IslanderColombianComoranCongoleseCook IslanderCosta RicanCroatianCubanCypriotCzechCongolese (DRC)DanishDjiboutianDominicanDutchDutch AntilleanEcuadorianEgyptianEmiratiEquatorial GuineanEritreanEstonianEthiopianFalkland IslanderFaroeseFijianFinnishFrenchFrench, MetropolitanFilipinoFrench GuianeseFrench PolynesianFrench Southern TerritoriesGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuadeloupeanGuamanianGuatemalanGuineanGuyaneseHaitianHeard And McDonald IslandsHonduranHong KongeseHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorian (Côte d'Ivoire)I-KiribatiJamaicanJapaneseJordanianKazakhstaniKenyanKittian And NevisianKuwaitiKyrgyzstaniLaotianLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgishMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartinicanMauritanianMauritianMahoranMexicanMicronesianMoldovanMonegasqueMongolianMontserratianMoroccanMosotho (Basotho)Motswana (Botswanan)MozambicanNamibianNauruanNepaliNew CaledonianNew ZealanderNicaraguanNigerienNigerianNiueanNi-VanuatuNorfolk IslanderNorth KoreanNorthern Mariana IslanderNorwegianOmaniPakistaniPalauanPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePuerto RicanQatariReunioneseRomanianRussianRwandanSahrawiSaint HelenianSaint LucianSaint-Pierrais And MiquelonnaisSalvadoranSammarineseSamoanSao TomeanSaudi ArabianSenegaleseSeychelloisSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth Georgia And South Sandwich IslanderSouth KoreanSpanishSri LankanSudaneseSurinamerSvalbard And Jan Mayen IslanderSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTimoreseTogoleseTokelauanTonganTrinidadianTunisianTurkishTurkmenTurks And Caicos IslanderTuvaluanUgandanUkrainianUnited States Minor Outlying IslanderUruguayanUzbekistaniVatican City ResidentVenezuelanVietnameseVincentianVirgin Islander (British)Virgin Islander (U.S.)Wallisian And FutunanYemeniYugoslavZambianZimbabwean Contact Info Date of Birth Gender MaleFemalePrefer Not to Say What is your expectation from this retreat? Emergency Contact - Name & Phone number How did you find out about the program? SelectThe Yoga Barn WebsiteFacebookInstagramFriend’s RecommendationOthers I accept the Terms & Conditions.
