Please allow 15 minutes or more to answer these questions.
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First name: *

 
Last Name: *

 
Telephone Number: *

 
Postal Address: *

 
Where did you hear about our Ziva Life Collective Retreat? *

 
How old are you? *

 
How old do you feel? *

 
What is your occupation? Do you love what you do? *

 
On a scale of 1 – 10, how much do you love yourself? *











 
On a scale of 1 – 10 how would you rate the current state, power and control of your - Mindset (how you think)? *











 
On a scale of 1 – 10 how would you rate the current state, power and control of your - Heartset (how you love)? *











 
On a scale of 1 – 10 how would you rate the current state, power and control of your - Healthset (your strength and vitality)? *











 
On a scale of 1 – 10 how would you rate the current state, power and control of your - Soulset (your connection with spirit)? *











 
Name 2 of the proudest moments in your life thus far? (1 personal, 1 professional) *

 
How do you want to be remembered when you leave this life? *

 
What is included in the weekend?
 
- 2 nights accommodation (twin share)
- All meals by award winning Chef Mark Jensen of Red Lantern
  ** Friday – Dinner
  ** Saturday - Breakfast, Lunch, Dinner
  ** Sunday - Breakfast, Brunch
  ** Beverages can be purchased from licensed bar at the venue.
- Workshop sessions and session materials
- Daily yoga and meditation classes.
- Surprise Adventure Excursion on Saturday afternoon.

 
Payment Details:
$1695

Please submit your payment details.  We will only process your payment once your application is approved.

*Visa, MasterCard & American Express accepted

 
Payment Details - Name on Card: *

 
Payment Details - Credit Card Number: *

 
Payment Details - Expiry Date (mm/yy): *

 
Payment Details - CCV Number: *

 
Disclaimer: I understand that each room is based on twin share accommodation and I am willing to connect with and share a room with another awesome woman. *

     
 
My friend is also applying for Ziva.  We would like to share the room together. Her name is...

 
Thank you for your application {{answer_wOBuyEmi6e0H}}, we'll be in touch soon.

- ZIVA LIFE COLLECTIVE

Thank you. We will be in touch soon!

- Ziva Life Collective
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