Retreat Form


Leah Lopez and Sam Tran are honoured to have you join the Release and Reclaim: Honouring your Inner Goddess Retreat.

We ask that you please take the time to carefully fill out all the areas of the form. We greatly appreciate it. Please do not hesitate to email us at if you have any questions or concerns. We will email you with more details closer to the day of the retreat.

Name *
Phone Number *
Phone Number
Emergency Contact *
Emergency Contact
Emergency Contact Number *
Emergency Contact Number
Have you purchased your ticket on Event Brite? *
Pre-registration is required for this event.
Both essential oils and sacred smoke will be used during the retreat. Please check below acknowledge that you are aware of this. *
The essential oils will be misted, used topically and potentially diffused throughout the day. You are welcome to pass on receiving topically. However, if you are sensitive to aromas, please know that they will be part of the retreat. If you are sensitive to smoke, please know that we will use cleansing sacred smoke and will have a fire pit burning at the end of the evening for our closing ceremony.
Waiver *
If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time in the class. It is important in yoga that you listen to your body and respect its limits at any given moment. I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. In further consideration of being permitted to participate in the yoga classes, I knowingly, voluntarily and expressly waive any claim I may have against the instructor, the owner or the leaseholder of the building for injuries or damages that I may sustain as a result of participating in classes or workshops led by Samantha Tran. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. Those under 18 years of age must have this form signed by a parent/guardian. By checking the box "I agree", you are agreeing to the terms of the waiver.
Photo Release *
Throughout the day, photographs will be taken by the two facilitators, Sam Tran and Leah Lopez. These photos will be used by us to promote future events. They will be used on our websites, social media and business platforms. We are respectful of the vulnerability and safety of the space that is created as we gather and will take photos only when we judge is appropriate. By checking "I agree", you hereby grant permission to Leah Lopez and Sam Tran to use photographs and/or video of me taken on September 28th, 2019 at Prairie Lotus Regina (and surrounding areas) in publications, news releases, online, and in other communications related to the mission of Leah Lopez' and Sam Tran's business.