Participant Registration
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Please share why you are drawn to this program
*
Pleas share your comfort level camping and in the outdoors
*
The program includes four nights of fasting, please share any concerns you have with this aspect or any previous experience
*
Have you participated in any Rite of Passage programs previously? If so, please share a few details. It will support us to support you more effectively knowing this info.
*
Please provide two emergency contacts
*
Full Name
Address
Contact Number
1
2
We provide simple plant based gluten free meals, please share any diet restrictions
Please share any medical conditions that would be helpful for us to know
*
Please share any allergies such as bee stings, pollen, penicillin, nuts etc..
This is an outdoor event and as with any outdoor activities there are natural hazards such as slippery stones, wasps, changeable weather.... Please click yes here to accept personal responsibility for your safety while on the program and sign below.
*
Please Select
Yes
Signature
*
Please acknowledge that we require a $100 nonrefundable desposit to secure your place on the program and that you will arrange to make full payment within 6 weeks of the program start date.
*
I acknowledge and agree
Once we have received your deposit, either Jaime or Toni will contact you to organise a preparation call. Please share which day and time of the week works best for you.
*
My Products
prev
next
( X )
Program Deposit
$
100.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: