December 2019 Embracing the Medicines Patziapa Retreat
Name
Date of Birth
E-mail
Phone number
Mailing Address
Nationality
Do you speak Spanish?
Fluent
A little
None
How did you find out about this trip?
Email newsletter
Spirit Jaguar website
Facebook
Friend
Other
Passport Number
Medical Conditions
Medications
Please list any dietary restrictions
Special Needs: (mobility, general issues etc.)
Emergency Contact information (name, e-mail, phone number)
Relationship of Emergency Contact (friend, spouse, parent, etc)
Submit
Should be Empty: