Fitrah Reset Psycho-Spiritual Retreat Program

Fitrah Reset Psycho-Spiritual Retreat Program

MADINAH & MAKKAH

APRIL 2020

Application Form

This application helps us determine whether this retreat is a good fit for you. Therefore, please read each question below and answer it as openly and authentically as you can! Do not skip any questions!

Full Name of Student *

First Name Last Name

Today's Date *

Date

E-mail of Student *

Your Age: *

Birth Date *

Month Day Year

Phone Number *

Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What do you currently do? *

Highest Education: *

Are You a Parent? (Y/N) *

Are You a U.S Citizen? *

IF not, please indicate your citizenship/residency status (i.e green card)

Please express your primary reasons for applying to this retreat? *

How would you describe your current spiritual, mental, and emotional health in life right now? How is your heart lately? *

Have you previously attended any of Dr. Marwa's courses or programs? If so, which one? *

What do you hope to gain spiritually, mentally, and emotionally from this retreat? *

Have you ever attended a retreat before? If so, what kind of retreat was it? How did it benefit you? What were your challenges? *

Have you completed umrah or hajj before? If so, how many times? *

How would your family and closest friends best describe your personality? *

How do you usually resolve conflict with others? *

What are some practices or things you do to improve your relationship with God and empower yourself spiritually? *

What are your current struggles when it comes to practicing Islam and improving your relationship with God? *

What are your current struggles when it comes to your relationship with yourself? *

What are some resources and outlets that you have utilized in the past to empower your mental and emotional health? (i.e, classes, programs, therapy, etc.) What was your experience like? *

Name 2 of your favorite Islamic books that you have read in the past (other than the Qu'an) and why you liked them. *

Outside of Islamic books, what are your favorite books and why? *

To your knowledge, do you feel like you are prepared and equipped mentally and emotionally to participate in this retreat? ( i.e. handle the regular stress of travel, be in a new environment, share a room with other program students, attend mandatory classes, and participate in the program activities and exercises) Please explain reasons for your answer. *

To your knowledge, do you feel like you are physically able to care for yourself throughout travels and the entire time of the retreat? If not, what are the factors that might impede your ability to physically care for yourself? *

Terms & Conditions: Please read each of the following program agreement terms and check each one that you have read and agreed to. In addition, please sign below indicating you have read and agreed to the terms of this program: *

By signing my name below, I am acknowledging that I have read, understood, and agreed to the program terms and conditions I have read above. By signing my name below, I am also agreeing that I have answered the above questions truthfully. And finally, by signing my name below, I understand that I am providing my signature indicating that I have agreed to apply for the Fitrah Reset Psycho-Spiritual Retreat Program and have agreed to the terms above. *

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