Peruvian Immersion 1 Retreat Application
Full Name *
Email Address *
Phone Number *
Skype address (if applicable) *
Facebook page (URL link) *
Passport Number *
Country of citizenship *
Birth Date *
Gender *
How did you find out about this retreat? *
Please let us know if you heard from a specific friend, Facebook, website, email, or other.
What do you dedicate your life/time to? (describe your work, projects, passions, other) *
Describe your motivation for participating in this retreat. *
What intentions/goals do you care to personally fulfill by participating in this experience? *
Check all that apply for your diet *
List any food allergies or intolerances and describe their severity *
Describe any physical conditions, diseases, or any health concerns. *
List any medications you are taking, particularly pharmaceuticals (including vaccines). *
Describe any mobility issues or physical constraints that we should know about *
Describe any mental illness, psychological conditions, or acute difficulties. *
Share any other comments, information or special instructions for us. *
Discount code
I acknowledge and accept that the 30% deposit to hold my place is non-refundable *
I confirm that Reviveolution recommends I wait to buy my plane ticket until I have been informed the minimum participant count has been met *
We will let you know no later than one month before
When bringing the remaining tuition in cash to Peru-- I commit to bring fresh bills with no tiny rips. *
This is good to remember for all cash you bring for your journey--- you will be unable to exchange ripped cash (even if it is the slightest bit). Take the time to get freshies!
I hereby give Reviveolution 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 program *
Emergency contact info *
Would you like to join our newsletter? *
We do not share our list
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