Registration for Tantra Massage for Couples

Your Full Name

Full Name of Your Partner

Your Email

Email of Your Partner

Your Phone Number

Year of Birth

Which program are you registering for?

Select from dropdown

Will you be paying via e-transfer (Bryarly@EarthNectar.ca) or credit card (note there is a 3% surcharge)?

Vocations of You and Your Partner

What do you and your partner hope to gain/experience/learn by attending this retreat?

What experience do you and your partner have in Tantra and/or other modalities that support your loving connection?

What are the current main stressors in your life?

Have you or your partner experienced any form of sexual, physical, or emotional abuse?

Yes

No

Rather not say

If yes to the previous question, and if you feel it important to share, please briefly explain. This information is kept strictly confidential and is only asked so we can better support you; it is not required.

Please also indicate whether you have received any therapeutic support regarding this abuse.

Do you have any health conditions, illnesses, infections, recent surgeries or injuries (within the past 12 months)? Click any that apply:

We will be doing physically active practices such as dynamic breathing and movement, as well as sitting and kneeling while giving the massage. Participants with health concerns should consult their doctor before registering.

NOTHING
Mental health condition (e.g., panic attacks, PTSD, bipolar disorder)
Neurological condition (e.g., epilepsy/seizure disorder, vertigo, migraines, concussion or traumatic brain injury)
Heart or cardiovascular conditions
Transmissible infection (e.g. respiratory or skin)
Knee, hip or back problems
Spinal injuries, pelvic or lower-body fractures
Recent surgery (within the past 12 months)
Other (specify below)

If you answered Other above, please specify any other body issues that the facilitator should be aware of.

have any health conditions, illnesses, infections, recent surgeries or injuries (within the past 12 months)? Click any that apply:

We will be doing physically active practices such as dynamic breathing and movement, as well as sitting and kneeling while giving the massage. Participants with health concerns should consult their doctor before registering.

NOTHING
Mental health condition (e.g., panic attacks, PTSD, bipolar disorder)
Neurological condition (e.g., epilepsy/seizure disorder, vertigo, migraines, concussion or traumatic brain injury)
Heart or cardiovascular conditions
Transmissible infection (e.g. respiratory or skin)
Knee, hip or back problems
Spinal injuries, pelvic or lower-body fractures
Recent surgery (within the past 12 months)
Other (specify below)

If you answered Other above, please specify any other body issues that your partner is dealing with.

Are you or your partner taking any medications? If so, please name them.

Is there anything else you or your partner would like to share about yourselves? (For example, it could be preferred personal pronouns, special needs, or anything else you want the facilitator to be aware of.)

Name and Phone Number of Emergency Contact

How did you hear about the retreat?

Do you agree to receive electronic communications from Bryarly McEachern (Earth Nectar)?

You can unsubscribe any time, by sending Bryarly@EarthNectar.ca an email with subject Unsubscribe, or by clicking the Unsubscribe link at the bottom of any newsletter.

Yes I agree to receive electronic communications from Bryarly McEachern (Earth Nectar).

Please read, understand and agree to our Terms and Conditions and Privacy Policy before submitting your registration form for the Event.

(Click on hyperlink below to view)

I have fully read, understand and I agree with all points in the Terms and Conditions and Privacy Policy.

LEAVING THE EVENT

I agree not to leave a practice or leave the Event without first talking to the retreat organizers or teacher.

PHOTO AND VIDEO CONSENT
When you arrive at the retreat, I will give you and your partner a consent form to fill, indicating whether you do or do not want photos/videos to be taken of you during the retreat. Photos and videos are only taken with a participant's consent, without nudity, and participants can request to check photos taken of them before they are used for promotion. Participants may request a copy of any photos/videos taken solely of them. Photos/videos, where permitted, are taken very sparingly, if at all.

OTHER PROGRAM DETAILS

Program payment: Payment is due when you submit your registration form. Please send your payment of $390 or $450 CAD immediately via e-transfer to Bryarly@EarthNectar.ca or by credit card (3% surcharge) via the Pay By Card link that appears after submitting this form. Your registration is complete after you have sent your payment. We will send you a confirmation email within 1 business day.

Retreat Schedule: Saturday November 7, 2026, 9:30 am - 7:00 pm

9:15-9:30 am Drop your things and go park

9:30-9:45 am Settle In (sign consent form)

9:45 am Opening and Morning Session

1:00-1:45 pm Lunch & Free Time

1:45 pm Afternoon Session & Short Break

6:45-7:00 pm Closing Circle

Please make sure you are committed to attending the whole retreat before registering and submitting your payment. Participants arriving late may be denied or delayed entry due to the sensitive and immersive nature of this retreat.

Orientation Information for Participants: A map of the retreat location, orientation information, and suggestions for what to bring, will be emailed to participants 2 weeks before the retreat, by October 24.

Cancellation Policy: Cancellation requests received at least 30 days before the start of the program will receive a full refund, minus a non-refundable deposit of $50.
Cancellation requests received less than 30 days before the start of the program will not be eligible for a refund. Exceptional circumstances may be considered by the organizer, in which case you may be eligible for a 50% program credit for use in other programs offered by the organizer within 1 year of the original program date.

CONFIRM AGREEMENT WITH OTHER PROGRAM DETAILS

I have read, understand, and agree with the Other Program Details mentioned above.