Conscious Experiences

Some forms take you places

INSTRUCTIONS

Please read the program details carefully and feel free to get in touch with us to address any questions you may wish answered prior to applying.

You will need the following information to complete the application:

Passport information
Emergency contact information
Medical history

We will get back to you within 3 working days with a confirmation and payment details. A deposit towards the program fee will need to be transferred within 48 hours of receiving the payment information.

Register before October 15th 2019 to get an EARLY BIRD DISCOUNT worth $350!

Don't like filling out long forms? Have a lovely conversation with our form instead! Seriously :)

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Given name/First name *

Middle name

Family name/Last name *

Email *

Contact Number *

What is your Date of Birth? *

Gender * Please share the gender you identify as.

Address line 1 *

Address line 2

City/Town/Village *

State/Region/Province *

Country *

Zip/Pin code *

Citizenship(s)/Passport countries *

Passport expiry date *

What is an area of growth that you wish to focus upon during the program? (Sustainability, Mindfulness, Yoga, Community, Other). Please elaborate. *

MEDICAL INFORMATION: Please indicate here in detail if you have

Any medical conditions.
Any psychological/psychiatric conditions
Any major injuries.
Any regular medication.

This is to help us best support you during the trip and also ascertain best fit for the program. * We strive to provide equal opportunities to people from all backgrounds and abilities. When in doubt, mention it. We are here for you :)

Any Queries? | Comments? | Anything you wish to add?

How did you find out about this program? *

Upload Passport Photocopy. Max size 200kb (you can use smallpdf.com or shortpixel.com to compress the size of your passport) * Scan only the data pages of your passport, typically the first and last page