ESTONIA REGISTRATION FORM
Application to attend Music Is Medicine, Estonia retreat with Poranguí and Ashley. Confidentiality Notice: This document is confidential and intended only for the use of retreat coordinators and facilitators. We request this information to help assure your safety, health, and suitability for this work. It helps us to understand what a person is or has been experiencing in order to tailor the program to best meet your goals and objectives for engaging with this program. Thank you for your candor and cooperation!
Which Retreat Are you Registering for? *
- 2024 MIM Estonia
I read all of the details and retreat rates on the registration page. *
Gender Identity *
- Female
- Male
- Non Binary
- Prefer Not to Say
Someone who will not be at the retreat with you
What is you proficiency in English? *
Select an option
Accommodations Preference *
A shared room the the main house is included in your registration fee- Upgrades for private accommodations are available for an additional cost
Select an option
Let us know if there are 1-2 people you would like to share a room with
What is your intention for this work and attending this retreat? *
Write as detailed as you wish.
- {name}
What benefits do you seek from this experience? *
Write as detailed as your wish.
- {name}
What are your expectations, if any? *
Write as detailed as your wish.
- {name}
Do you have any apprehensions or concerns? *
Write as detailed as you wish. Please be candid and honest. This helps us know how to support you best.
- {name}
Describe your general state of fitness and health. Indicate any known health conditions or possible health concerns. *
- {name}
Have you visited a health care provider for a health-related issue within the past year? If so, for what reason? *
- {name}
Dietary Preferences & Allergies *
The retreat is professionally catered and all food will be vegan and gluten-free. Please describe in detail any specific dietary allergies or preferences beyond this so we can best accommodate your needs.
- {name}
Do you have any allergies? If so, do you require anti-allergic medication in case of exposure? *
Include any food allergies.
- {name}
Are you or have you ever been treated for any kind of mental illness or disorder, including depression, bipolar disorder, schizophrenia, or other conditions not listed? If so, please describe in detail. *
The presence of these conditions does not exclude you from participation. All information will be held in strict confidentiality. This helps us know how to support you best.
- {name}
If any, are these experiences active or in remission? *
- {name}
What are your current active treatments (if any) including any current medications and dosages? *
- {name}
Please note any physical limitations which might affect your ability to participate in some physical activities? *
- {name}
Describe your stamina and fitness for walking or hiking. (Moderate hiking is included in these retreats) *
Moderate hiking is optional in these retreats, please let us know your ability to participate in these kinds of activities.
- I have a disability or fitness issue which would prevent my participation.
- I can participate in light to moderately strenuous hiking up to one mile.
- I can participate in light to strenuous hiking up to two or three miles.
- I enjoy walks of any length and difficulty.
Describe your experience with making music (voice, instruments, theory, production, etc). No experience necessary! *
- {name}
Describe your experience with any healing modalities, personal development and consciousness exploration. (No experience necessary!) *
- {name}
Travel Info
Will you be driving to the retreat center, flying into Estonia, renting a car, open to ride share, etc? Leave blank if you're not sure yet.
- {name}
How did you hear about our retreat? *
- Email List
- Facebook
- Instagram
- Word of Mouth
- At a live concert
- Music is Medicine Online Community
- Other
We use this to easily share with the group at the end of the retreat to keep in touch.
We use this to easily share with the group at the end of the retreat to keep in touch.
Please add any comments you feel would be helpful to get to know you better. *
- {name}
Would you like to join Poranguí's email list?
We typically send monthly newsletters with announcements, new music, podcasts, etc. (If yes, click the box)
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