Awaken Anahata Retreat
Welcome - whatever brought you to this point in your journey, I see you and celebrate you on this HUGE Step.

I invite you to fill out this application and agreement form for consideration of this Retreat:
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Email *
First Name: *
Last Name: *
Address: *
Phone Number: *
Date of Birth *
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Birth City *
Birth Time *
Time
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Emergency Contact, Phone Number and Email. *
Special food requirements? *
What is your favourite meal? *
ANY known medical conditions, if comfortable sharing? *
Please list all current medications, if comfortable sharing?
Any special requests or comments? *
How did you find out about this retreat? *
Why Now? *
If accepted, what are you looking to accomplish or heal? *
I, the signee of this application acknowledge while in at the Awaken Anahata Retreat, I give my permission to work with Jesse Kunes and Kinterest Group LLC as well as permission to deserve, allow, receive, and, believe in anything and everything meant for me in this transformational process.
I, the signee of this application confirm I have NOT been diagnosed with schizophrenia, bipolar disorder, known serious heart conditions or extreme high blood pressure. *
Required
I, the signee of this application confirm no use of chemical substances, illicit or prescription, from 2 weeks before, during and 2 weeks after the retreat. Absolutely no SSRI's, or MAOI should be taken during or around your retreat. *
Required
I, the signee of this application understand that all payments are final and nonrefundable (this does not include initial deposits as the retreat is filled). In the case that the signee cannot participate in the retreat for any reason or for any unforeseen circumstance the retreat is inaccessible for a period of time a credit for the retreat will be issued and available to be used at a future date in accordance/coordination with Jesse Kunes and the retreat center. *
Required
I, the signee of this application acknowledge am here to inspire my own personal growth and transformation, I alone am responsible for the well-being and perception of my life. I take full responsibility for my individual experience and outcome associated with this service/program and beyond. Under no circumstances will Jesse Kunes or Kinterest Group LLC, heirs, guardians, legal representatives of/and Jesse Kunes and Kinterest Group LLC be held responsible for my actions or circumstances. I hereby and forever release, wave, and discharge any claims against Jesse Kunes, Kinterest Group LLC, and any of their associates affiliates or family. *
Required
I, the signee of this application understand that Jesse Kunes, Kinterest Group LLC, and Affiliates are not medical doctors and are not recognized to diagnose, treat, or cure any disease or illness. You should always consult with your medical doctor before making any changes to your diet, prescription medications, lifestyle, or exercise program. *
Required
I, the signee have carefully and thoroughly read and understand this agreement. I am aware that by my typed signature I am agreeing to and legally bound to the aforementioned statements and I accept these terms with gratitude and of my individual Free Will choice. *
Required
Date of Submittal *
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Please Type Your Name to Confirm and Agree to the entirety of this application and agreement. *
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