*** Please print out this form for you to complete. ***

SACRED MEDICINE JOURNEY
COSTA RICA

2016 Registration Form


I am registering for:

______ January 31st - February 8th



NAME:
_________________________________________

ADDRESS:
_________________________________________

_________________________________________

_________________________________________

PHONE:
_________________________________________

CELL:
_________________________________________

EMAIL:
_________________________________________


DIETARY NEEDS OR HEALTH ISSUES:

_________________________________________

TOTAL INTENDED LENGTH OF STAY IN COSTA RICA:

*** For people choosing to stay in Costa Rica before or after the the course.

___________________________


TOTAL INTENDED PAYMENT: ________________


PAYMENT SENT UPON REGISTRATION: ________________

PLEASE CHECK THOSE THAT APPLY:

( ) I am sending my payment in full.

( ) I have sent my deposit of $200 to hold my space. (non-refundable)

( ) I have sent my deposit of $_______ plus $_______ of my payment.


*** Must initial to complete registration:


* Make checks payable to The Gaia School of Healing.

* Send completed retreat registration form and payments to:
The Gaia School of Healing - California Branch, c/o Marysia Miernowska, 2635 28th St. #1, Santa Monica, CA 90405

Contact by phone or email: 310-866-7095, thegaiaschoolca@gmail.com





Please feel free to contact Marysia with any questions, at thegaiaschoolca@gmail.com, or call 310-866-7095.



Please take the time to answer the questions below so that we can learn more about you.


How did you find out about the Costa Rica Sacred Medicine Journey?


What are your specific interests regarding plants, healing, and spiritual practice?



What are you most looking forward to learning and experiencing during this course? What are your desires and expectations?








Do you have any questions about the course or your stay at La Cusinga that you would like answered?










Please take some time to tell Marysia about yourself, and to ask her any questions that you have regarding this retreat. If you have any special needs or concerns, please voice them so that we can try to address them well before the start of the retreat.












We look forward to you joining us!
Green Blessings, The Gaia School

The Gaia School of Healing & Earth Education ~ California Branch
c/o Marysia Miernowska
2635 28th St. #1
Santa Monica, CA 90405

thegaiaschoolca@gmail.com
310-866-7095