Name

First Name

Last Name

Phone

Country

(###)

###

####

Mailing Address

How would you like Jackie to contact you?

Via email

Via text/iMessage

Via WhatsApp

Via Phone Call

Any of the above

How did you hear about the retreat?

What interests you about the retreat?

Have you ever practiced meditation?

Please note that a meditation practice isn't a prerequisite!

Yes, all the time!

I practice sporadically.

I've tried it, but I don't practice regularly.

I've tried it, and it's not for me.

I'm excited to try!

Is there anything you want to share about your feelings towards meditation?

This isn't required but please feel free to take up the space if you need it!

Do you have any other mindfulness practices? Ritualized routines? Please feel free to share as much or little as you feel comfortable.

What is your relationship to movement?

Do you workout? Practice yoga? Have a daily step goal? Are you into pilates? Alternatively, does movement intimidate you? Have you had any injuries that hinder you from movement? Do you live more of a sedentary lifestyle? There's no judgement here. Please share anything you feel is relevant.

This retreat is an investment (financially, emotionally, energetically) in your growth. Not the kind that requires you "hustle hard" or "just push through", but the kind that invites you to soften into presence, beauty, connection, and pleasure. Are you ready to commit to yourself in this way ~ to say yes to easeful transformation, soulful nourishment, and experiences that expand you gently (but also meaningfully)? (Please feel free to take up space and share anything that may have come up for you with this question!)

What room type are you interested in?

Private (double bed for one)

Private (double bed for two)

Shared room (single bed)

Shared room (double bed for one)

Shared room (double bed for two)

If interested in a shared room:

I'm booking and traveling with a friend

I'm coming solo and will be sharing with a new friend

What rate are you interested in?

Discounted paid in full

$750 deposit with 5 additional payments

$750 deposit with 10 additional payments

Please list any dietary restrictions (or note that you have none).

Please list any physical injuries, conditions or surgeries that impact your physical or mental health (or note that you have none).

Please list your emergency contact information (name, phone number, email) as well as your relationship to them:

Please use this space if there is anything else you'd like to share that you feel may be relevant.

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say, “yes” to saturnia, italy