Membership Information You have selected the Quad –Payment Plan membership level. Please note that the $100 registration fee is included, and this is non-refundable. The price for membership is $100.00 now and then $100.00 after 1 Month. Account Information Username Password Show Password Confirm Password Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Personal Information Full Name Email Cell Phone Number 1st Roommate’s Full Name 2nd Roommate’s Full Name 3rd Roommate’s Full Name 4th Roommate’s Full Name Emergency Contact Emergency Contact Full Name Emergency Contact Relationship Emergency Contact Phone List Any Food Allergies Please provide any food allergies or any diet restrictions below. If none just type N/A Divine Virtue LLC Retreat T-Shirt Size Please select your T-Shirt size Adult Small Adult Medium Adult Large Adult XL Adult 2X Adult 3X Adult 4X Acknowledgement By submitting this registration form, I grant Divine Virtue LLC, permission to take photographs and videos of me during the Divine Virtue Wellness Retreat. I understand that these images and videos may be used for promotional purposes, including but not limited to social media, websites, marketing materials and other publications related to the retreat. I acknowledge that I will not receive compensation for the use of these images or videos, and I waive any rights to the images once they are taken. By checking the box below, I consent to the use of my image in accordance with the terms outlined in this waiver. I consent to the use of my image for promotional purposes as directed above. I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease. Payment Information Pay with Credit Card Card Number Expiration Date CVC Processing...
