Visionary Journeys between Medicine and Magic

Booking Form

Please fill-in all relevant fields to conform with our booking process.

Programme

Programme *

Preferred Date to Start Your Retreat (dd/mm/yy):

Alternative Preferred Date to Start Your Retreat (dd/mm/yy):

Length of staying (total number of weeks/days):

Travel Details

Include flight number, carrier name, date and time of arrival for applicable flight details.

National flight details: arrival in Iquitos (if known/applicable)

National flight details: departure from Iquitos (if known/applicable)

Number of travelers:

Personal Details

Title:*

First Name: *

Middle Name:

Family Name / Last Name: *

Age: *

Address: *

City: *

ZIP/Postal Code: *

State: *

Country: *

Daytime phone: *

Evening Phone:

Mobile Phone:

Fax:

Email *

Verify Email *

Alternative Email

Vegetarian: *

Date of Birth (dd/mm/yy): *

Place of Birth: *

Nationality: *

Passport Number: *

Country of Issue: *

Issue Date: *

Date of Expiry: *

Contact in case of emergency: *

Other

Interpreter Spanish-English required: *
 Yes No

Please note that the interpreter is mandatory if you don't speak good Spanish, for the Ayahuasca/Shamanic Plant Diet retreat in Ashi Meraya

Where did you hear about us? Check all the boxes applicable:

 Word of mouth/referral by a friend Advert on a magazine Advert on the internet Search engine Article on a magazine/newspaper Other (Please specify)

Payment: *
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 I will make the full payment soon

Comments:

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I voluntarily agree to fully abide to these conditions as written.

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