Well Being Center Services

* These fields are required

1 Welcome

2 This does not include accommodations

3 People in your group

Guest 1		First Name* Last Name* Gender* Email*
Guest 1		First Name* Last Name* Gender* Email*

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4 Wellbeing Center Services

Therapeutic Bodywork Session - 60 minutes

$90.00

Select quantity

Therapeutic Bodywork Session - 90 minutes

$120.00

Select quantity

Thai Yoga Therapy Session - 90 minutes

$140.00

Select quantity

Hot Stone Therapy - 90 minutes

$140.00

Select quantity

Therapeutic Conditioning - 45 minutes with 15 min follow-up

$75.00

Select quantity

Bliss Treatment

$150.00

Select quantity

Ayurvedic Consultation

$150.00

Select quantity

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5 Participant Information

Spiritual Name
Gender *	If you are staying in a dorm or double shared room and you selected Other Gender, please explain in the Comments box below under Additional Information.
Birth Date *
Have you been at the Ranch before? *	YES NO
How did you hear about us? *

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6 Contact Information

Cell Phone *
Alternate Phone
Address
Address 2
City
State/Prov.
Zip/Postal
Country

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7 Emergency Contact Info

Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact E-mail
Medical Issues	If none, please enter 'none'.
Prescribed medications	If none, please enter 'none'
Illnesses
Comments or Special Needs
How will you arrive?	Private Vehicle (Arriving before 6:00 PM) Private Vehicle (Arriving after 6:00 PM) Bus (Arriving at 12:47 PM) Bus (Arriving at 2:57 PM) Bus (Arriving at 5:20 PM) Bus (Arriving at 6:58 PM) Please call us if your transportation plans change. For bus arrivals, we will collect you from the Citgo gas station in Woodbourne.

8 Agreements

Ashram Guidelines and Cancellation Policy	I have read and agree to the Ashram Guidelines and Cancellation PolicyPlease read the Ashram Etiquette, Guidelines and Cancellation Policy
Email newsletter *	Please send me the email newsletter No thank you

9 Well Being Center

Date *	Enter date of treatment.
Time of Appointment *

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10 Total

Sub Total	$0

Donations	$0

Taxes	$0

100% Deposit	$0

Due Now	$0 $0

First Name
Last Name
Address *
City *
State/Province *
Postal/Zip Code *
Country *
Card Type
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

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