Zuna Tribe Retreat in Sicily: May 28 - June 4, 2022
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Personal details
First Name *
Last Name *
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Health Information
Are you under medical treatment for any physical condition? *
Are you currently pregnant or trying to get pregnant? *
Do you have any chronic pain, physical limitations, or disabilities? *
Have you had a serious illness or major surgery within the last five years? *
Do you have a communicable disease? *
Are you under medical treatment for any psychiatric condition? *
Have you ever been hospitalized for any psychiatric condition? *
Are you in recovery for an addiction? *
Have you ever been in a treatment program for alcohol or substance abuse? *
If you answered yes to any of the above, please describe fully.
Do you currently have, or ever had, any of the following conditions?
Environmental or food allergies *
Respiratory conditions *
Heart conditions *
Diagnosed mental-health conditions *
Seizures or strokes *
Chemical sensitivities *
Diabetes *
High blood pressure *
Injuries *
If you answered yes to any of the above, or if you have any other health condition that could impact your full participation in the program, please describe fully.
Please list any prescription medications you are currently taking, indicating dosage and frequency of intake, and what symptoms/conditions require the medication—excluding birth control and cosmetic prescriptions.
Please list all dietary restrictions including dairy, eggs, fish, meat. Please specify if you are vegetarian or vegan.
Emergency Contact
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