Personal Mesa Intensive Form
Full Name *
Email Address *
Phone Number *
Skype address (if applicable) *
Facebook page (URL link) *
Passport Number *
Country of citizenship *
Birth Date *
MM
/
DD
/
YYYY
Gender *
How did you find out about Reviveolution? *
Please let us know if you heard from a specific friend, Facebook, website, email, or other.
List the dates you desire to participate in your Personal Mesa Intensive *
Are you signing up for a private intensive, or a shared? (in some cases there may not be an option depending on participant interest) *
What specific line of work or projects do you dedicate your time to? *
Describe your motivation for participating in this intensive. *
What intentions/goals do you care to fulfill by participating in this experience? *
Check all that apply for your diet *
Required
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. *
Do you plan to stay in the provided accommodations in Huaran all 4 nights? *
I accept the terms and conditions of the refund policy. (If you decide to cancel, the deposit is non-refundable. We listen to each person on a case by case basis, and in some cases, may come to an alternative agreement) *
Required
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 intensive on their website and in print material for the use in promotion of their projects and programs *
Emergency contact info *
Would you like to join our newsletter? *
We do not share our list
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Additional Terms