Circus Island Application 2021/22
Applications now open for December 2021 & January, 2022
Sign in to Google
to save your progress.
Date of Birth
What country are you a citizen of?
What country are you currently residing?
When would you like to join us?
NYE December 20th, 2021 - January 2nd, 2022
How long would you like to stay?
NYE 2 Week Immersion
What type of accommodation would you like to stay in?
Twin Shared Room / Couples Room
Private Room for individual
Do you plan on working online while in-residency?
Yes, under 10 hours a week.
Yes, 10 - 20 hours a week.
Yes, 20+ hours a week.
No, I plan on being fully present in the program.
Are you looking for an investment option to a permanent community?
What best describes your main intention to come to a Residency?
Learn new skills with a like minded community while traveling.
Live mid - long term in community while working remotely.
Investing in the future - I am ready to move to community permanently.
Do you have a personal project / business venture? Please describe.
What does it mean to be awake?
Do you consent to us using the words above for marketing purposes?
How did you hear about Momentom?
Friend or family
At a festival or live event
At a studio or jam
Please specify name of friend / studio / event
What is your intention for coming to Momentom?
Your Website (leave blank if n/a)
Your Whatsapp (leave blank if n/a)
Is there anything else you'd like to share with us?
Are you interested in joining in medicine ceremonies with us? (additional fee - only cacao is included in residency fees)
Are you interested in receiving healing modalities? (all one on ones are at additional costs)
Energy & Crystal Healing
Past Life Regression
Shamanic Drum Journey
Have you been to a Momentom Residency before? If so, which one and which year?
Thank you for your submission. We will be in touch with information on the next steps.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Momentom Collective.