Shake Your Soul Retreat Registration Form

Yes! So excited for you to join this body, heart, and soul nourishing retreat. Please fill out this form and go ahead and register (even if you're waiting for a friend to sign up too. I'll give you a retroactive refund when she signs up :). And please know that I will keep anything that you share here confidential.

First name*

Last name*

Email*

Phone (Use +972 before your number without the 0)*

City of Residence*

What do you hope to receive from the retreat?

Is there anything else that you would like me to know?

How did you hear about this retreat?

Friends

WhatsApp message

Malka Sima's Website

Malka Sima's email newsletter

Facebook

Other

If a friend referred you and/or encouraged you to join, please share her name here. You will both receive a 50 shekel discount (to be received retroactively when she signs up.)

Please pay 480 shekels by one of the following options:*

Israeli Credit Card (I'll send you a link with option for up to 3 payments)

Bit or Paybox 0526121364

Paypal - malkasimapais@gmail.com

In cash at the retreat

Bank Transfer - details when you submit this form

Already paid

Waiver:

I understand that I am participating in a therapeutic movement class that includes instructions in physical movements, meditation, and self discovery. I recognize that this practice has inherent risks that include bodily injury and I understand that this class is not a substitute for medical or psychotherapeutic treatment. I hearby accept and take full responsibility for any and all risks associated with participation in this class.

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