Iboga Retreat Application Form
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Which Retreat date do you want to sign up for?
August 23- August 29 with Michael
November 5-12th with Lilla and Greg
December 10th-17th with Lilla and Greg
January 7th-15th (I.A.M. retreat) with Michael and Dan
January with Michael 21th-28th
Feb with Michael 4th-11th
Feb with Michael 18th-25th
Date of Birth
Country, State/Province, City
Are you on any recreational or pharmaceutical drug(s)? Please list.
Do you have an alcohol dependency?
Do you suffer from any illnesses? Mental, emotional, spiritual or physical. Please explain.
Reason for participating in an Iboga Ceremony?
Do you have any questions
How did you hear about us?
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This form was created inside of Bwiti Living & Learning Center.