Dr Amba's Speakers/Attendees
APPLICATION
Legal Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
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Best Time to Call and Time Zone
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E-mail
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-Shirt Size
Please Select
Small
Medium
Large
XL
2X
3X
Names of past Events, Retreats or Courses with Dr Amba
If No Experience with Dr Amba- please watch this video and reply with 1 or 2 of the 5 Yin organs EMOTION(s)- that you most resonate with most often. https://youtu.be/a-IoLxSgpPo?si=w01pFjT5Zw0CWfJ7
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Liver- Wood Element
Heart - Fire Element
Spleen - Earth Element
Lungs - Metal Element
Kidneys - Water Element
Briefly Describe Your Relationship With Spirituality?
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Have you done any personal development before -what sort?
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Have you had any mental health crises in the lsat 2 years?
List Any Training, Education or Spiritual Gifts That Have Shaped You To Serve Others
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In Case of Emergency Person to Contact
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Reference Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
I hereby release all such persons or entities from liability that may result or arise from attending Dr Amba's Retreats if I am accepted to attend. Should my application be accepted, I agree to follow the policies and code of conduct and maintain kindness, patience with every other attendee. I understand that this personal information will be held confidential and if any situation arises where I feel uneasy- I will speak directly with Dr Amba or her assistant privately as soon as possible.
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I agree with the statement above
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