To reserve your place on this program, please complete and submit the form below. Your attention and completion of the entire form will be helpful to us to determine your specific health needs. This data will be processed through a SECURE form and will only be used for the purposes of this workshop and/or your health treatment.
We will get back to you with more information and confirmation details soon.
Flights to Costa Rica are usually booked through Delta or Continental Airlines and range in price from $450.00-$590.00. These flights have a layover in Houston, Texas, and then continue to Central America totally 8-11 hours total travel time. At your arrival a chartered Turismo-style van will shuttle you to the Finca Ipe Retreat Center. Please contact us for further travel information and we will assist you in booking the best, most convenient flight.
Questions marked with * must be completed. |
Huna Vida Retreat Registration
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First Name *: |
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| Last Name* |
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Email address*: |
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Home address*: |
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Address 2: |
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| City*: |
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| Zip / Post code* |
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State*: |
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| Contact Telephone number: |
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Country: |
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Nationality |
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| Date of birth |
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Level of Spanish |
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Occupation
(if student see below): |
Student:
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Other:
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Payment:
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Payment Method |
Check
Credit Card
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If Check, check #: |
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Credit Card Type: |
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Credit Card Number: |
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Credit Card Exp Date: |
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Emergency contact info*: |
| Name: |
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| Relationship to you: |
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Emergency number (if different from above): |
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| Emergency email: |
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| Your Passport number |
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Optional travel: please indicate if you are interested in this option |
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References - List two references we may contact, if needed: |
Name: |
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Phone: |
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Name: |
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Phone: |
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How did you find us: |
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| Which Workshop are you signing up for ? (both week long Costa Rica and 1 day Santa Cruz workshops are listed in the drop down menu) |
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HEALTH INFORMATION
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Your health and your diet: (Please state any allergies, health problems or dietary requirements or anything you think we should be aware of.): |
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What type of work do you do? Describe. e.g. - Secretary: Mostly sedentary. Sit at desk and type., or Construction work: heavy lifting and vigorous physical labor. |
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| Fitness Level: |
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1 - (Sedentary: little or no exercise)
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2 - (Intermediate: regular moderate exercise)
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3 - (Athletic: daily exercise or training of one hour or more)
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Have you ever received Chiropractic/massage/Fitness Training/Physical Therapy before?
If yes, Please describe in detail the reason and the results. If treatment was for several injuries, please list. |
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Have you ever had surgery on any part of your body before? Describe in detail where, when and how and the results, please. |
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Please indicate what type of medications you are taking currently. What are they used for? Such as aspirin/Tylenol, pain killers, muscle relaxers, insulin, tranquilizers, sleep aids, birth control pills or others |
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| Do you take vitamin supplements? |
YES
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Do you drink coffee, tea, alcoholic beverages, or soda beverages?
How many cups/cans per week? |
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Do you smoke cigarettes? How many per week? |
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Comment: (Please use this for any questions or comments.): |
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