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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri 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*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Portrait 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.