Ceremony Passenger Info

1

Name* This field is required

First Name

Last Name

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2

Email* This field is required

example@example.com

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3

Phone Number* This field is required

Area Code

Phone Number

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4

Height* This field is required

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5

Weight* This field is required

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6

Age* This field is required

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7

Current Home City & State* This field is required

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8

Profession

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9

Emergency Contact Person w/Phone* This field is required

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10

What are your interests and intentions in attending the meditation? What are the things in your life that you seek to change, improve or reinforce?* This field is required

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11

Do you have prior experience with this type of meditation? Please briefly explain how long you have participated in the meditations and any outcomes you have had.* This field is required

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12

If you have not had experience with this meditation, have you had any other type of mind-expanding experience?* This field is required

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13

Please inform us of any medical conditions you have had in the past and any medical conditions you are currently dealing with (diagnosed or undiagnosed).* This field is required

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14

Please list any medications/drugs, natural medicines or supplements, and vitamins that you are presently taking. If you will need to take any of these during the time of the meditation, please inform us which ones.* This field is required

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15

Have you ever been hospitalized or treated for any kind of mental illness or disorder including depression, bipolar disorder, schizophrenia, or other condition? If so, please explain below.* This field is required

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16

Have you ever suffered a seizure, if so please explain below.* This field is required

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17

Do you feel physically, emotionally, and psychologically prepared to experience this type of meditation?* This field is required

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18

What are three things you LOVE in this world and why?* This field is required

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19

Anything else? Questions? Things we should know? Are you interested in one or both nights?

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20

How did you hear about us?

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