Retreat Application Form This application form is for you who have not joined a retreat with Swaha before. Please complete the following 3 steps: 1 Personal Information2 Your Health3 Your Life Name* First Last Address* Street Address City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint MartinSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Other PhoneEmail* Enter Email Confirm Email Skype Contact NameIf you have a Skype account.Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Portrait picture*Upload a small portrait picture of yourself - like the one in your passport or drivers license. Allowed file formats are jpg,gif and pngAccepted file types: jpg, png, gif, jpeg.Contact Person - Name*Who should we contact in case of an emergency? First Last Contact Person - Phone*Contact Person Email* Contact Person - Relation*How is this person related to you? (Mother, Father etc.) 1. Do you have any disabilities or health issues?*YesNoWhich health issues?*2. Do you have any allergy or any contagious disease?*YesNoWhich allergy or disease?*3. Are you or have been under psychiatric treatment?*YesNoWhen have you received treatment, for how long and and for what reason?*4. Do you take any prescription drugs or any other drugs?*YesNoWhat kind of drugs, and for what reason?* 5. What are you doing in your life or working with now?*6. Have you participated in any therapy groups?*YesNoWhich therapy groups?*7. Do you have any experience with meditation?*YesNoWhat kind of meditations?*8. How did you get to know about the retreat and Swaha? If it was through a person, who was it?*9. Have you been to Satsang before?*YesNoWhere and with whom?*10. What is most important for you in your life? Mention one or several things.*11. Mention something that has been very important in your life.*12. Are you willing to look at yourself in this retreat?*YesNo13. What do you seek when joining a retreat with Swaha? (write at least 5 lines).* This iframe contains the logic required to handle Ajax powered Gravity Forms.