Ayni Mama Retreat Intake Form 2026

Mother's Information

First Name *

Last Name *

Full Address *

Street Number, City, State, Zip

Phone *

Emergency Contact

(EC) First Name *

(EC) Last Name *

(EC) Phone *

Care & Well-Being

(Optional, Confidential)

Dietary preferences, restrictions, or allergies.

Medical considerations we should be aware of:

Mom's T-Shirt Size *

Small

Medium

Large

Daughter's Information

Daughter's First Name *

Daughter's Last Name *

Daughter's Birthday *

Care & Well-Being

(Optional, Confidential)

Daughter's Dietary preferences, restrictions, or allergies.

Daughter's medical considerations we should be aware of:

Daughter's T-Shirt Size *

Youth Extra Small

Youth Small

Youth Medium

Youth Large

Intentions for the Retreat

What are your main intentions for joining this experience? *

Deepen Connection

Create Shared Rituals

Slow down and be more present.

Build confidence and emotional awareness.

Nature connection and embodiment

Emotional Healing

(Select up to three)

What You’d Love to Take Away

What would you love your daughter to experience or feel during this retreat?

What would you love to experience or take away as a mother?

Is there a ritual, practice, or feeling you hope to bring home with you?

Expectations & Boundaries

Are there any boundaries, concerns, or needs you’d like us to be aware of?

Communication & Connection

Would you like to schedule a brief connection call prior to the retreat? *

Yes

No

Preferred Method of Communication *

Email

Text

Who referred you to Ayni Mama *

Will you be attending with a friend and want to be in the same area/house?

Anything else you’d like us to know as we prepare to welcome you and your daughter?