Medical Retreat
Application

Personal Information

First Name*

Last Name*

Gender*

SelectMaleFemaleOther

Date of Birth

MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Day12345678910111213141516171819202122232425262728293031

Contact Information

Email Address*

Phone Number*

Address*

City*

State/Province*

Postal Code*

Country*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship to Emergency Contact*

Medical Information

Do you have any medical treatment booked? If so, please provide details (treatment, provider, dates):*

Would you like us to arrange medical treatment with our partners? If so, please specify the treatment and preferred dates:*

Retreat Details

Preferred Dates for Retreat*

Group Name (if applicable)

Number of People in Your Group, Names, Ages, Genders, and Experience Levels*

Health and Dietary Information

Do you have any dietary restrictions? If yes, please specify.

Do you have any allergies or sensitivities? If yes, please specify.

Do you have any medical conditions or special needs? If yes, please specify.

Pickleball Information

Pickleball Skill Level*

BeginnerIntermediateAdvanced

Preferred Lesson Type*

Group LessonsIndividual CoachingBoth

Do you have any specific goals or areas of improvement you'd like to focus on during the retreat?

Activities

Other than Pickleball, what other local activities do you think you will be interested in?*

Additional Information

How did you hear about our Pickleball Retreat?*

Any additional comments or requests:

I acknowledge that I am participating in physical activities and/or receiving medical treatments at my own risk. I hereby release the organizers, instructors, and associated entities from any liability, injury, or harm that may occur during the activities or treatments.

Once the form is submitted, we will review your requests and someone will get back to you soon.
If you require more immediate assistance, or if you don't hear back from us, please feel free to reach out:
Phone +506 6156-4187 or via email at retreats@purapickleballcr.com.