Microdosing and Movement: A Bright Future Retreat

Microdosing & Movement: A Bright Future Retreat
Let's get started!

As we begin planning our Microdosing & Movement: A Bright Future Retreat, we will be fielding all interested applicants with a brief questionnaire. After completing this form, a $300.00 refundable payment will be taken. Accepted applicants can use this payment towards their total payment of the retreat upon acceptance. We invite you to take a few calming breaths, center yourself, and proceed with an open heart.
Participant Name*

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemaleNon-BinaryPrefer not to sayOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail*
example@example.com
How would you describe your life at this point in time?*
What about this retreat sparks your interest?*
Tell us where you are at right now in your life that makes you want to attend a retreat.*
Have you attended any other retreats in the past? If yes, please tell us about that experience.*
What is your experience with psychedelics? Please describe this in detail. We'd like to know amount(s) used before, set and setting, what was your experience like, what did you like, what did you like?*
Where do you want to see yourself in 6 months? In 12 months? The more specific you can be here, the better.*
What are the desired outcomes that you hope to achieve?*
What is stopping you from making this a reality right now?*
How do you think that this retreat can support you with achieving those goals?*
Do you have any dietary preferences?*

VeganVegetarianPescatarianGluten-FreeOther
Let's explore your medical background. Please indicate if you or your family member has been diagnosed with any of the following:*

Borderline Personality DisorderSchizophreniaPsychosisBipolar DisorderParanoid Personality DisorderNeurological DisorderChronic DepressionEating DisorderOther
If other, please feel free to elaborate below:
Indicate if you are taking any of the following medication, and why:*

AntiboticsAntihistaminesSSRIsMAOIsSteroidsLithiumL-tryptophanEphedraKavaOther
Do you have any health conditions we should be aware of? (Example: Cardiovascular issues, Blood pressure, etc)*
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

Clear
At this time, we will request your credit card for a $300.00 Application Fee to Microdosing and Movement: A Bright Future Retreat. Please note that if your application is not approved, you will not be charged and/or refunded the total amount. If you wish to pay by a different format, please reach out to getbrightfuture@protonmail.com
You will hear back about your application within the next 72 hours.

My Products

Application FeeMicrodosing and Movement: A Bright Future Retreat

$300.00CAD Quantity

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Microdosing & Movement: A Bright Future Retreat

Let's get started!