Goddess Application

Full Name *

Nickname

Date of Birth & Age *

Email Address *

Phone/Cell Number *

Emergency Contact Name *

Emergency Contact Phone/Cell Number *

Mailing Address *

Are you pregnant? *

YES

NO

Have you served in the Military? *

YES

NO

Do you have any allergies? If so what are they? (Please list all) *

Do you have any food restrictions? If so what are they? *

Do you have any restrictions for long distance walks or hiking? *

YES

No

Do you have any medical conditions? If yes, please list all. *

If you have any of these/ or if they apply to you please check the box's below. *

Are you currently taking any medications? If yes, please list all. *

Are you currently taking any mind altering drugs? *

YES

NO

Are you currently struggling with an addiction of any sort or struggling mentally? If yes, is there anything that we should be aware of at this time? *

Have you or are you currently suffering from post pardon-depression? *

YES

NO

Have you suffered major trauma? *

YES

NO

Have you been sexually abused? *

YES

NO

Do you have any sensitivity to sound or smell? If yes, please explain on which or both. *

What are you trying to achieve? Overcome? Heal? etc. *

Have you done any holistic or energy work? If yes, please list the things you have done or been apart of. *

Do you have a business you would like to share with the group? *

YES

NO

How did you hear about the retreat? *

By registering and attending Awaken The Goddess Retreat, you understand and agree that a photographer will be taking photos and videos at the event including a photoshoot the very last day. We may publish them to any format or media without additional permission from you if you are in the photo. *

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You agree that you have answered all questions honestly in order for us to take the best precautions for everyone in attendance, including youself. *

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