I AM HAITI RETREAT — INITIAL INTEREST APPLICATION

I AM HAITI RETREAT — INITIAL INTEREST APPLICATION

Please fill out this application to express your interest in the retreat.
This experience is intentionally intimate and selective. Participation is limited to 20 individuals whose energy, openness, adaptability, and readiness align with the intention of this retreat. Completing this application does not guarantee acceptance. We review each submission with care to ensure group harmony, safety, and shared purpose.
Full Legal Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Application Fee*
prevnext( X )
Application Fee
Non-refundable application fee

$25.00

Total

$0.00
Email*
example@example.com
City/State/Country*
Emergency Contact + Phone*
Emergency Contact Name
Emergency Contact Relationship
Passport status*
International travel experience*
Haiti visit history*
If yes, please describe your Haiti visit history
Medical conditions impacting activity*
If yes, please explain medical conditions
Any physical limitations or injuries?
Dietary Restrictions or Allergies
Please specify your dietary restrictions or allergies
Dietary needs or allergies?
Please specify any specific dietary preferences or restrictions not already covered
Mental health or emotional well-being history
Previous retreat or group experience
What are your specific goals or intentions for this retreat?
What is your usual level of physical activity?

SedentaryLightly activeModerately activeVery activeExtremely active
Medications affecting physical activity or climate adjustment?
Activities of interest (Select multiple)

Yoga + meditationBreathworkHiking/mountainsBeach timeHorseback ridingFarming/plantingFishingCooking cultural mealsLearning language basicsGrounding barefoot outdoorsCultural ceremoniesDigital detox
What excites you most about this retreat?
What challenges or concerns do you have?
Minimalist Readiness (Select all that apply)

Understanding non-hotel experienceComfort with shared/simple accommodationsOpenness to limited electricity and waterPacking lightlyWillingness to disconnect from phone/internetOpenness to cultural immersion
Describe your thoughts on group behavior and energy contribution:
What does cultural immersion mean to you?
What draws you to experience Haiti and its culture?
How do you view the importance of simplicity in life?
What value do you see in an all-inclusive retreat?
Are there any individuals (names and contacts) you recommend or wish to connect with for this retreat?
Do you have any questions or concerns for us before deciding?
Confirm your honesty agreement by signing below.*
Date*
Travel Insurance Provider
Do you plan to travel with a companion?

YesNo
If yes, please provide your companion's details
Health Insurance Provider
Health Insurance Policy Number
Should be Empty: