Eighteen Day Ayahuasca Retreat in Peru

* These fields are required

Price

$4,650.00 – (US)

Participant Info

First Name *
Last Name *
Email *
Gender *
Birth Date *
Phone
Address
Address 2
City
State/Prov.
Zip/Postal
Country
Passport Number	We must report all program participants to the National Reserve and they request this information.
Emergency Contact Info	Name and phone number
Dietary restrictions
Diet Details	Special considerations or anything else you'd like to mention regarding your diet
Physical Health	CHECK ANY AND ALL THAT APPLY: Low Blood Pressure High Blood Pressure Heart Surgery Heart Attack Irregular Heartbeat Chest Pain Circulation Problems Diabetes Meningitis Migraines Epilepsy Hyperthyroidism Hypothyroidism Cancer or Tumor HIV/AIDS Asthma Ulcer Obesity Chronic Pain Fibromyalgia Arthritis Aneurysm Stroke Head Injury Neurological Disease Infectious Disease Gynaecological Condition Other (please specify)
Physical Health Details	If you want to provide more detailed information
Psychological Health	CHECK ANY CONDITIONS BELOW that you are currently experiencing: Schizophrenia Depression Paranoia Panic attacks Obsessive Compulsive Disorder Suicidal Thoughts Post-Traumatic Stress Disorder Psychosis Bipolar Disorder Eating Disorder Chronic Anxiety Autism Asperger’s Borderline Personality Disorder Depersonalisation Disorder Multiple Personality Disorder Self-Harm Other, please specify
Psychological Health Details	If you want to provide more detailed information
How Would You Describe Your Current State of Health?	Write "healthy" if you have no issues
Medication you are currently taking	Pharmaceutical, natural, vitamins, supplements, etc.
Will you be sharing a room? With whom?	Please provide the name of the person who will share a room with you, or just answer 'no'
What else should we know about you?
Email newsletter	Please send me the email newsletter
Terms and Conditions *	I accept the terms and conditions.click to read the Terms and Conditions
Confirm you are real *	Type the letters and numbers you see above to verify that you are actually a person.

Payment

Sub Total	$0

Taxes	$0

Deposit	$0

Due Now	$0 $0

Choose Payment Option

	You will be contacted soon with instructions for paying the deposit using an alternative method. Click on the button below and these instructions will be repeated on the next page.

	You will be asked for credit card details in the next step. Click the button below to continue.

	Retreat Guru is the online booking agent for Ayahuasca Foundation. Charges will appear on your bill as "Retreat Guru"

Eighteen Day Ayahuasca Retreat in Peru – $4650

Price

Participant Info

Payment