Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Do you currently live in Portugal or Poland?

Yes

No

Deposit / Payment Completed *

Paypal

Bank Transfer

Other

Are you on any prescription or other medication? *

Yes

No

Do you have a history of mental illness?

Yes

No

Terms & Conditions of My Registration *

http://www.lineageoflight.com/cancellation-policy/

I have read, understand and agree to the Terms & Conditions of Lineage of Light Retreats, including the Cancellation Policy