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APPLY BELOW FOR YOUR HEALING EARTH AND PLANT SPIRIT MEDICINE RETREAT
SAKRD
APPLICATION FORM
First Name
Preferred Name
Email Address
Last Name
Phone
Date of Birth
Current Address Including City / Town
In order to confirm your identity, please upload a copy of a government-issued photo ID.*
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Place of Birth
Relationship Status
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship To You
Occupation
Please list any past or present physical health conditions.
Please list any past or present psychological health conditions. Some examples include: schizophrenia, paranoia, depression, anxiety, multiple personality disorder, bipolar disorder, PTSD, ADD, ADHD, self harm, eating disorder, panic attacks, obsessive compulsive disorder, etc.
Are you taking any prescription drugs for these / other conditions?
Have you ever been diagnosed or treated for any addiction?
Do you have a family history of addiction (drug, alcohol, or other)?
Are you currently taking any SSRIs (Selective Serotonin Reuptake Inhibitors)?
Yes
No
Do you have any allergies or sensitivities (food, medication, other)? Please share your reaction(s) to them as well.
What is your current / preferred diet?
Do you have a history of trauma? If so, please give some background on the experiences in your life.
Lastly please share your intention for wanting to participate in this type of journey experience. Take your time with this question as your intention plays a major role in your journey experience.
As the next step in the registration process, a Zoom call will need to be scheduled
I agree.
I do NOT agree.
What type of journey experience would you like to explore?
BESPOKE (Only you.) $9800 CAD
COUPLES (You and your partner / person of choice). $7900 CAD Total
INDIVIDUAL (Would be part of a group setting.) $1650 CAD Each
What days would you prefer your SAKRD journey?
Weekends (Friday - Sunday)
Weekdays (Monday - Wednesday)
No preference.
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I have read and understand the Privacy Policy & Terms and Conditions (see link above) and agree to abide by their terms.
Yes
No
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Today's Date
I declare that the information I’ve provided is accurate and complete.
I want to subscribe to the newsletter.
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Thank you for your application.
NOT READY TO APPLY BUT WANT TO KNOW MORE?
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