Registration form Ampiri 2019
please fill this form and we will get back to you ASAP to complete your registration
Email *
Full Name *
Age *
Gender *
Phone Number *
Country of origin *
Are you suffering from any medical conditions? please specify. (choose "Other" for yes) *
Are you taking any pills or medication regularly? please specify. *
What would you like to get from your time at Ampiri? *
do you have any experience with the following? please check the relevant boxes.
To which of the retreats would you like to register? *
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