Primordial Breathwork Teacher Training Interest List

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* These fields are required

1 Welcome

2 Participant Info

Confirm Email *
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
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.
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.
Please list all the prerequisite programs you have completed with the Paititi Institute
Healing Modalities you Practice & Level of Practice
List any Degrees, Accreditations and/or Licenses you hold (including date obtained & date of expiration)	State "none" if not applicable.
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)
How do you foresee applying this certification in your life?
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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