English Application - Samadhi Journeys

Thanks for joing us

Please fill out the application form below as accurately as possible. This document is confidential and is used to help assure your safety, health and suitability for this work. We value creating a healthy group dynamic conducive to your personal growth. Therefore, we only accept a limited amount of participants. Send us an email with any questions or for more information about customized retreat experiences. We are looking forward to meeting you!

Name

Email Address

Phone

Birth Date

What country are you from?

What retreat did you sign up for?

Emergency Contact Phone Number

Emergency Contact

Occupation

Do you have experience with ethogenics? If yes, please share more about your experiences.

What is your intention for this work and attending this retreat?

Describe your general state of fitness and health. Indicate any known health conditions or possible health concerns.

Please note any physical limitations which might affect your ability to participate in some physical activities?

Do you have high blood pressure or any heart condition? Do you have high blood pressure or any heart condition? Yes No

Have you visited a health care provider for a health-related issue within the past year? If so, for what reason?

Are you or have you ever been treated for any kind of mental illness or disorder, including depression, bipolar disorder, schizophrenia, or other conditions not listed? If so, please describe in detail.

If any, are these experiences active or in remission?

Do you have any allergies? If so, do you require anti-allergic medication in case of exposure? (please also note any food allergies)

What are your current active treatments (if any) including any current medications and dosages?

Have you received a Cov&d vaccine within the last 5 weeks? Have you received a Cov&d vaccine within the last 5 weeks? Yes No

How did you hear about us?