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pachamama ecstatic dance retreat


Please review the information on the retreat page including dates, costs, & curriculum for this retreat and fill out the information below.

Note: All information provided in this application is for school use only and will be used to determine eligibility for the specific program you are interested in. All information will be held in the strictest confidence and will not be shared externally.

Dates: june 21-27, 2020



You must be at least 18 years of age to participate in this retreat.


Please answer the questions below honestly and completely. If you have any further questions please email
Legal Name *
Legal Name
Full Address *
Full Address
Phone Number *
Phone Number
Date of Birth
Date of Birth
Emergency Contact
Emergency Contact
Emergency Contact Phone Number
Emergency Contact Phone Number
Emergency Contact Cell Number
Emergency Contact Cell Number

Related Experience

How long have you been practicing yoga?
Within the past year, how many times on average do you practice yoga per week?
How long have you been exploring a dance practice?
Within the past year, how many times on average do you practice dance per week?

Health Information

Please indicate if you currently have or have a history of the following conditions in your lifetime:

Short Answer


I acknowledge that all information submitted in this application is true and accurate. I have read the criteria listed above, and understand that it is my responsibility to consult with a physician regarding my participation in this retreat. I am physically fit and I have no medical condition that would prevent my participation in the program. I take full responsibility for my own pacing of what I can and cannot do during the retreat. I understand that the retreat activities are voluntary and I will honour my wellbeing by not pushing myself beyond my capacity. I assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Pachamama Ecstatic Dance Retreat. I will not hold any of the facilitators for this training responsible for any injuries or actions arising out of, or in any way connected to my participation in this program. I acknowledge that a risk of personal injury may be involved in any exercise, yoga or dance program, and understand that it is my responsibility to refrain from performing any movements that cause me pain or discomfort, physically or emotionally. I, my heirs and legal representatives forever release, waive, discharge and covenant not to sue or make claims of any kind against Awakened Spirit Yoga or any of the aforementioned parties for any injury, property damage/loss, or death caused by their negligence or other acts.