In Your Element Retreat Application

We are so excited to invite you on this beautiful personal journey

through the 5 Elements

Melissa & Belle xx

Personal Details

First name

Last name

Date of Birth

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Emergency Contact

Name

Relationship to you

Phone

Travel Information

Do you hold a valid passport (6+ months validity from retreat end date?)

Yes

Please note all participants are responsible for obtaining the required entry visa for Bali.

Health & Wellbeing

Do you have any medical conditions (physical or mental health) we should be aware of? If yes, please give an overview.

Are you currently taking any medication? If yes, please list what and what for.

Do you have any injuries or physical limitations we should know about?

Are you able to walk up stairs without assistance?

Yes

Are you able to carry your own luggage?

Yes

Are you able to participate in daily practices such as yoga, meditation, and light movement?

Yes

Have you ever been diagnosed with or currently been treated for a mental health disorder? If yes, please give an overview.

Do you have any history of substance misuse or additions we should be aware of? If yes, please give an overview.

Do you have any heart condition, high/low blood pressure, epilepsy, history of aneurysm, asthma or respiratory issues that may affect your ability to safely participate in breathwork practices?

Disclaimer: Certain retreat practices - including breathwork, and intensive emotional release work - may not be suitable for individuals with heart conditions, high/low blood pressure, epilepsy, history of aneurysm, asthma or respiratory issues or psychological conditions. By submitting this form, you confirm that you have disclosed any relevant conditions and agree to seek medical clearance if necessary. participation is at your own risk, and facilitators are not liable for undisclosed health information.

Lifestyle & Safety

Are you willing to remain alcohol-free and substance-free for the full 7 days of the retreat?

Yes

Are you willing to participate fully in group activities, healing processes, and discussions, even when it feels emotionally or physically challenging?

Yes

Are you comfortable with periods of silence, reflection, and personal practice as part of the retreat schedule?

Yes

Dietary Needs

Do you have any food allergies or intolerances? If yes, please list below.

Are there any foods that you must avoid due to medical reasons? If yes, please list.

Do you have an anaphylactic allergy?

Yes

If you have an anaphylactic allergy you will be required to carry an in date Epi-Pen on your person at all times during the retreat. It is also recommended to bring a spare.

Do you follow a specific diet (vegan, gluten-free, dairy-free, low histamine, etc)?If yes, please list.

Intentions & Alignment

What is calling you to join this retreat at this time?

What are your intentions and hopes for your healing journey during this retreat?

Have you attended retreats or intensives healing programs before? If yes, please share briefly.

Is there anything that may affect your ability to fully participate in the retreat experience?

Agreements

By applying, you acknowledge and agree that:

This retreat is a healing intensive space and is alcohol-free and substance-free.

You are responsible for arranging comprehensive travel insurance and providing proof before the retreat.

You are physically able to participate in daily activities (Kundalini yoga, meditation, breathwork, ceremonies, walking).

You understand that the facilitators are not medical doctors therefore can't give any advise in regards to medical issues or treatment.

You understand that the facilitators are not licensed therapists as in psychiatrist or psychologist therefore can't give advise on undiagnosed or diagnosed mental health issues.

You consent to share accurate and honest health information for your own safety and the wellbeing of the group.

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Terms & Conditions

Payment Schedule

Deposit: A non-refundable deposit of $500 AUD is required at the time of approval to secure your spot.
Balance: The remaining balance is due 8 weeks before the retreat start date (by 27th April 2026).
If you apply and are accepted less than 8 weeks prior, full payment is required at the time of approval.
Afterpay is available (surcharge applies)

Cancellation & Refund Policy

Refunds are calculated on the amount paid less than the $500 AUD deposit.

More than 16 weeks before the retreat (before 2 March 2026): 100% refund of balance (less $500 non-refundable deposit)
Between 12 - 16 weeks before (3 - 30 March 2026) 50% refund of balance (less $500 non-refundable deposit)
Between 8 - 12 weeks before (31 March - 26 April 2026) 25% refund of balance (less $500 non-refundable deposit)
Within 8 weeks of the retreat (27 April 2026 onwards) No refunds will be given under any circumstances.

Transfer of Booking

If you are unable to attend, your booked spot may be transferred to another suitable person, subject to approval by the organisers.
The replacement guest must complete the application process and be accepted.
Transfers may be requested any time before the retreat (even within 4 weeks), provided the replacement is approved.

Travel Insurance (Mandatory Requirement)

Comprehensive travel insurance is mandatory for all participants and must be arranged independently.
Proof of valid insurance cover must be provided prior to the retreat.
Insurance MUST cover at minimum:
- Trip cancellation and curtailment
- Overseas medical expenses and hospital cover
- Medical evacuation and repatriation
- Lost or delayed baggage
Complimentary credit-card insurance is often insufficient, participants must ensure their policy provides adequate cover
Participants MUST provide proof of adequate insurance cover to the organisers

Additional Terms & Conditions

No refunds will be given for late arrivals, early departures, or no-shows.
All cancellations must be submitted in writing (email).
The organisers reserve the right to cancel or reschedule the retreat due to unforeseen circumstances (e.g. government restrictions or safety concerns). In such cases, participants will be offered either:
- A full refund of all monies paid (including deposit) or
- A transfer of funds to a rescheduled retreat date.
The organisers are not responsible for expenses incurred outside retreat fees (e.g. flights, visa, transfers, insurance costs or food and drinks, activities, or sundries other than what has been stated in the inclusions).
Participation is subject to acceptance through the application process. The organisers reserve the right to decline and application if the retreat is deemed unsuitable for the participant.

I acknowledge that I have read and accept the terms and conditions of the retreat.

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