Feminine Roots Application
Full Name
Your answer
Email Address
Your answer
Phone Number
Your answer
Skype address (if applicable)
Your answer
Facebook page (URL link)
Your answer
Passport Number
Your answer
Country of citizenship
Your answer
Birth Date
MM
/
DD
/
YYYY
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.
Your answer
What is your highest prayer for the planet and global community at this time?
Your answer
Why is it important for women to gather?
Your answer
Describe your motivation for participating in this retreat.
Your answer
List Special Skills, Talents, Inspirations and Passions
Your answer
What intentions/goals do you care to fulfill by participating in this experience?
Your answer
Check all that apply for your diet diet
Required
List any food allergies or intolerances and describe their severity
Your answer
Describe any physical conditions, diseases, or any health concerns.
Your answer
List any medications you are taking, particularly pharmaceuticals (including vaccines).
Your answer
Describe any mobility issues or physical constraints that we should know about
Your answer
Describe any mental illness, psychological conditions, or acute difficulties.
Your answer
Share any other comments, information or special instructions for us.
Your answer
Discount code
Your answer
I have thoroughly read the Feminine Roots DETAILS DOC found on Reviveolution.net
I understand the details of flights, payments and discounts, waiting for my acceptance letter, and other important information
Required
I accept the terms and conditions of the refund policy.
Required
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 August 26th to offer you sufficient time for flights!
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
Your answer
Email newsletter?
We do not share our list
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms