Long Program Registration 2019-06-27T15:54:26+00:00

Long Program Registration Form

This is the registration form for our long programs. If you would like to take part in the 9 Day Ayahuasca Retreat please register here.

Program:

Ideal Start Date:

Is your start date flexible? YesNo

Name:

Nationality:

Email Address:

Phone:

Age:

Sex: MaleFemaleTrans

   
Dietry Restrictions:

 
Do you have any allergies or dietry requirements we should be aware of? (If yes, please give details below):

Have you ever suffered or currently suffer from any of these conditions? High Blood PressureCirculatory ProblemsIrregular HeartbeatHeart SurgeryHeart AttackAneurismMental DisorderSchizophreniaClinical DepressionBipolarDiabetesStrokeEpilepsyAnxiety DisorderOCDInfectious DiseaseAutism

Are you currently taking any medication? (If yes, please give details below):

 
Please add any further comments or questions if you have any.

How did you hear about this retreat?

We usually respond to all bookings with 2 days. Occasionally registration emails go missing. If you do not hear from us with 3 days please email: raomisboayahuasca@gmail.com