Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

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What type of accommodation are you interested in? *

Only 1 bunk spot left!

Shared Double Room - 2 Twin Beds

Shared Double Room - 1 King

Private Room - Queen or King

Shared Bunk Room - 4 Beds

How will you be attending? *

If you planning to share a room with someone please include their name and email in the additional comments.

Solo

With family/friends

Meals *

Bloom is a vegetarian facility

Gluten Free

No Dairy

Vegan

No Restrictions

Emergency Contact *

First Name

Last Name

Emergency Contact Phone # *

(###)

###

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How Would You Like to Pay? *

E-transfer to connect@jafferyoga.com

Credit Card