CodeSpaVRregistrationForm

Welcome to the CodeSpa Virtual Reality and 360 Maker Retreat!

Please complete all of the items on this form (in one session, as your input will not be saved until you submit). Providing the demographic information will help us in evaluating the diversity of our programs. Providing your health information will allow us to best care for your needs. Your information will be kept confidential.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Age *

Gender *

Racial/Ethnic/Cultural Identifications *

Spiritual/Religious Affiliations *

Sexual Orientation *

Income Level (Low, Middle, High) *

Are you temporarily or permanently physically disabled or mentally challenged? If so, what is your condition: *

State specifically and practically, one goal in participating in this retreat: *

How did you hear about this retreat? *

Select Your First Choice of Accommodation [Remaining Balance due 30 days prior to retreat] *

Select Your Second Choice of Accommodation [Remaining Balance due 30 days prior to retreat] *

If you are attending with someone and wish to be roommates, please list their name(s) here: *

What type of phone will you be using? *

Android iPhone

What type of laptop will you bring? *

PC Mac

Please share your dietary restrictions so that we can provide options for your meals: *

Are there any other health conditions, surgeries or medications you have had that may affect your participation? *

Please list an emergency contact person, including their name, phone number, and relationship to you: *

Anything else you would like to share? *

Submit

Thank you!
You will receive further information from us as the retreat gets near. If you have questions in the meantime, please contact us at codespavr@gmail.com

Thank you!You will receive further information from us as the retreat gets near. If you have questions in the meantime, please contact us at codespavr@gmail.com ​​

Thank you!
You will receive further information from us as the retreat gets near. If you have questions in the meantime, please contact us at codespavr@gmail.com