Apply | Selva Madre

APPLICATION

THIS APPLICATION WILL NOT CONFIRM YOUR BOOKING BUT WILL START THE PROCESS
Upon receiving your application, our bookings team will reach out promptly to schedule an intake call.
You may also email us at peruselvamadre@gmail.com

Your Name

Preferred Pronoun

Code

Phone

Nationality

Date of Birth

Length of Visit

Date of Arrival

Date of Departure

Introduction

Diet

Medical History

Medications

Addictions

Intention

Questions

Emergency Contact

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Please read all sections of What To Expect and acknowledge

I have read all sections of What To Expect. I understand that I will need to pay a $500 US deposit in order to finalize my reservation. I also understand that this deposit is nonrefundable if I cancel my trip for any reason. Deposits may be credited to trips that are rescheduled.

Please note: Deposits should be sent through PayPal - PeruSelvaMadre@gmail.com. PayPal will charge a fee of $22.45 when a payment is marked as "Goods and Services" rather than "Friends and Family". If you choose to mark your payment as "Goods and Services", please change your deposit to $522.45.

Legal Disclaimer
Before continuing, please read our Safety Page and acknowledge by signing your name below with a digital signature.

I swear I have answered all questions above honestly. I have read the Safety Page and I take full responsibility for any harm that might come to me, including my death, if I fail to follow the safety instructions. I also acknowledge that you may terminate my retreat at any time if you discover any health conditions that would make it unsafe for me to continue.

APPLICATION

THIS APPLICATION WILL NOT CONFIRM YOUR BOOKING BUT WILL START THE PROCESS
Upon receiving your application, our bookings team will reach out promptly to schedule an intake call.
You may also email us at peruselvamadre@gmail.com

Legal Disclaimer
Before continuing, please read our Safety Page and acknowledge by signing your name below with a digital signature.

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PeruSelvaMadre@gmail.com

Selva Madre, Peru

APPLICATION

THIS APPLICATION WILL NOT CONFIRM YOUR BOOKING BUT WILL START THE PROCESS Upon receiving your application, our bookings team will reach out promptly to schedule an intake call. You may also email us at peruselvamadre@gmail.com

Legal Disclaimer Before continuing, please read our Safety Page and acknowledge by signing your name below with a digital signature.

THIS APPLICATION WILL NOT CONFIRM YOUR BOOKING BUT WILL START THE PROCESS
Upon receiving your application, our bookings team will reach out promptly to schedule an intake call.
You may also email us at peruselvamadre@gmail.com

Legal Disclaimer
Before continuing, please read our Safety Page and acknowledge by signing your name below with a digital signature.