Amazon: 16-day Embodying True Nature Immersion

	$2,333.00 to $2,888.00 – Sliding Scale - SHARED ROOM or Room with PRIVATE BATHROOM (first come first serve)
	$ Please enter an amount *

Confirm Email *
Second Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
URL link to your Facebook Page *	This is used so we can create a facebook group for participants of this program.
Country of Citizenship *
Passport Number *
Birth Date *
Gender *
Profession *
Emergency Contact Info *	Please include Full Name, Relationship, Phone & Email
Requested Roommate	More info regarding room options will be sent at a later date. We will do our best to honor your request.
Dietary Restrictions? *
Allergies? *	Food, medicine, specific insects, etc.? List "none" if you have no allergies.
Describe ALL Medical Issues *	Enter "none" if you have no issues.
Are you pregnant? *	Yes No
Do you smoke tobacco? *
Do you have a history of epilepsy or a neurological condition? *	Yes No
Do you have any heart or blood preasure conditions? *	If yes, please share details.
Do you have a history of mental illness? *	Have you ever been diagnosed and/or hospitalized due to mental illness? If no, please state "none".
Describe all Surgeries and/or Hospitalizations in the last 5 years. *	State "none" if not applicable.
Please list all supplements & pharmaceutical mediations. *	List all by name, dosage and reason for taking. State "none" if you don't take medications.
Any pharmaceuticals you recently stopped taking? *	List all medications you stopped taking in the last year and what they where taken for.
Birth Control (IUD or pills)? *	Please share the details of your birth control method. If not applicable state "none".
Additional Comments or Special Needs? *	Any additional health & care information not listed above that we should be aware of.
Describe your experience hiking in the mountains with a pack & spending extended time without modern amenities. *	We will be in a backcountry setting, off the grid and with no services.
Wilderness Medical Training? *	WFA, WFR, etc. If yes, please share the specifics.
Have you ever been convicted of a felony? *	If yes please explain. *A past felony does not disqualify you however it is important information in supporting your transformation journey.
Have you ever served in the Armed Forces? *	If yes please elaborate.
Tell us a bit about yourself & your personal spiritual, healing and transformation journey. *	(please include your experience with meditation, shamanism, sacred plant ceremonies or any other modalities)
Please list your goals and the specific issues you would like to work on during this retreat: *	physical, emotional and/or spiritual
Why do you feel this program would benefit you & what inspired you to apply? *
Special Skills, Talents, Inspirations and Passions *
Any additional info you would like to share?
How did you hear about this program and the Paititi Institute? *
I hereby give The Paititi Institute permission to use my photographic likeness in images taken during this retreat on their website and in print material for the use in promotion of their projects and programs. *	YES NO
Email newsletter	Yes, please sign me up for the email newsletter!We do not share our list
Terms, Conditions, Release of Liability & Assumption of Risk *	I accept the terms and conditions.Read Terms and Conditions Here
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Amazon: 16-day Embodying True Nature Immersion

1 Welcome

2 Contribution

3 Participant Info

4 Make an Additional Love Offering to Support our Shared Heart Vision

5 Contribution

$	For the benefit of all beings. Through the resources we generate we are committed to continuing our development of a regenerative and reproducible model which can give back to humanity on many levels.
$	Donate to our Scholarship Fund Contribute to our scholarship fund and make it possible for others with financial challenges to join our programs on a full or partial scholarship!