January 2018 Kauai Yoga Retreat: Registration Form

* Please be sure to first read our Retreat Registration Policy for information on rates, discounts, deadlines & policies as well as, payment options.

Kauai Yoga, Meditation & Sound Wellness Retreat:
January 13th – 19th, 2018

Thank you for joining our exclusive retreat on Kauai.  Our aim is to offer you an experience of your highest truth and light as you expand…Into the Bliss!

Please completely fill out the form below to complete your reservation and registration for this retreat.

Note: We will be holding this retreat in January 2018. When booking, please specify which date you are interested in joining. Of course, you are welcome to join us for both!

Please completely fill-out the form below, then click “Submit” to secure your reservation.

Your Name (required)

Phone Number (include U.S. & International Area Codes)

Your Email (required)

Street Address

Street Address #2 (if applicable)




Room Preference
All room options are first come, first serve following full payment reservations.

Method of Payment

I have read the (January 2018) Kauai Retreat Registration Policy

Digital Print Signature

Please type your full legal name here to confirm your contact information, plus registration details with deposit or full payment to confirm your spot.

Emergency Contact (full name)

Emergency Contact Phone (include U.S. & International area codes)

Are You Planning to Rent a Car?

Injuries or Medical Conditions (please list here)

Please also include any conditions or helpful details we should aware of during the retreat.

Food Allergies &/or Special Requests?

All meals will be primarily vegetarian (although there will be eggs at breakfast & fresh local fish on two or three evenings.

Other Allergies or Information?

Please include any other allergies and details for retreat organizers here.

Contemplation Point: What are your highest intentions for the retreat?

There will be plenty of time for journaling and reflecting on your experience(s). What you learn at this retreat you can use the rest of your life!

Additional Notes

Important Note:
If paying by Paypal: make note of the total amount based on your room preference from above, as you will have to manually enter this amount into Paypal after you click the "Pay Now" button below.

If paying by Check: make note of the total amount based on your room preference from above, then click the "Pay Now" button below to submit your form. (Disregard the Paypal screen that follows.)

Questions before booking?

Call Diane at 1-(480) 244-7676 or send an email via the Contact page.