{"id":1866,"date":"2024-12-26T12:49:36","date_gmt":"2024-12-26T12:49:36","guid":{"rendered":"https:\/\/naturaliaretreat.com\/?page_id=1866"},"modified":"2024-12-30T22:14:44","modified_gmt":"2024-12-30T22:14:44","slug":"application-form","status":"publish","type":"page","link":"https:\/\/naturaliaretreat.com\/en\/application-form\/","title":{"rendered":"Application Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1866\" class=\"elementor elementor-1866\">\n\t\t\t\t<div class=\"elementor-element elementor-element-77194e8 e-flex e-con-boxed e-con e-parent\" data-id=\"77194e8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8d0901e elementor-widget elementor-widget-shortcode\" data-id=\"8d0901e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container \" id=\"wpforms-1859\"><form id=\"wpforms-form-1859\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1859\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1866\" data-token=\"00cd603a4ee91d0c3097657d7900658f\" data-token-time=\"1780502755\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1859-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1859-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-1859-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1859-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-1859-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1859-field_4-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1859-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_4_1\" name=\"wpforms[fields][4]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_4_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_4_2\" name=\"wpforms[fields][4]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_4_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_4_3\" name=\"wpforms[fields][4]\" value=\"Prefer not to say\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_4_3\">Prefer not to say<\/label><\/li><\/ul><\/div>\t\t<div id=\"wpforms-1859-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1859-field_2\" >retreat that responsibility<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1859-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1859-field_8-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_8\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1859-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1859-field_9-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_9\">Mobile number with country code <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1859-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" step=\"any\" required><\/div><div id=\"wpforms-1859-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_10\">Date of birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1859-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-1859-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_11\">Arrival date at the retreat (please, remember retreats starts on Mondays, so this date must coincide with any Monday of the year)  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1859-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-1859-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_12\">Emergency contact information <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1859-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-1859-field_13-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_13\">Have you had any injuries or accidents? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1859-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/textarea><\/div><div id=\"wpforms-1859-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_14\">Have you participated in an Ayahuasca Ceremony in the past? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1859-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/textarea><\/div><div id=\"wpforms-1859-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_15\">Do you follow a specific diet? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1859-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" required><\/textarea><\/div><div id=\"wpforms-1859-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><label class=\"wpforms-field-label\">Do you have any of the following:<\/label><ul id=\"wpforms-1859-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Allergies\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_1\">Allergies<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_2\" name=\"wpforms[fields][16][]\" value=\"Asthma\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_2\">Asthma<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_3\" name=\"wpforms[fields][16][]\" value=\"Claustrophobia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_3\">Claustrophobia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_9\" name=\"wpforms[fields][16][]\" value=\"Depression\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_9\">Depression<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_8\" name=\"wpforms[fields][16][]\" value=\"Diabetes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_8\">Diabetes<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_7\" name=\"wpforms[fields][16][]\" value=\"Epilepsy\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_7\">Epilepsy<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_6\" name=\"wpforms[fields][16][]\" value=\"Heart disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_6\">Heart disease<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_5\" name=\"wpforms[fields][16][]\" value=\"High blood pressure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_5\">High blood pressure<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_4\" name=\"wpforms[fields][16][]\" value=\"Blood disorder\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_4\">Blood disorder<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1859-field_16_10\" name=\"wpforms[fields][16][]\" value=\"Bipolar disorder \/ schizophrenia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_16_10\">Bipolar disorder \/ schizophrenia<\/label><\/li><\/ul><\/div><div id=\"wpforms-1859-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_17\">Beside of the above, do you take any medication or tablets? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1859-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/textarea><\/div><div id=\"wpforms-1859-field_18-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_18\">Did\/do you consume any type of drug? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1859-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required><\/textarea><\/div><div id=\"wpforms-1859-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><label class=\"wpforms-field-label\">Do you drink alcohol? *<\/label><ul id=\"wpforms-1859-field_19\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_19_1\" name=\"wpforms[fields][19]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_19_2\" name=\"wpforms[fields][19]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_19_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1859-field_20-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1859-field_20\">If yes, please mention an average quantity and frequency<\/label><textarea id=\"wpforms-1859-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/textarea><\/div><div id=\"wpforms-1859-field_22-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"22\"><label class=\"wpforms-field-label\">Terms and conditions: By submitting this form, I certify that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. I certify that by the time of the retreat I will not have consumed any recreational drugs for a month, nor prescription for anxiety\/depression\/sleep for 2 weeks or any other undisclosed medicines. I understand that failure to do this implies to put my health at serious risk. I acknowledge that I will be provided with information and advice intended for my safety. I understand that any consequences arising from my decision not to follow such information and advice shall be my sole responsibility. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1859-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1859-field_22_1\" name=\"wpforms[fields][22]\" value=\"I agree\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1859-field_22_1\">I agree<\/label><\/li><\/ul><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-1859-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-1859-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page 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value=\"https:\/\/naturaliaretreat.com\/en\/wp-json\/wp\/v2\/pages\/1866\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1859\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/naturaliaretreat.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"unboxed","site-sidebar-style":"unboxed","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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