Pure.Wild.Self Intake Form

Your full name as stated in your passport(Required)

Passport number(Required)

Nationality(Required)

Please list your nationality as stated in your passport.

Preferred name(Required)

How do you like to be addressed?

Pronouns(Required)

Phone(Required)

Email(Required)

WhatsApp Number(Required)

Please download the WhatsApp app for communication while at the retreat.

Date of birth(Required)

Imiloa is a plant-based vegan kitchen. The following questions relate to your allergies that the team needs to be aware of:

What foods cause an allergic reaction?

When was the last reaction?

How many times have you had a reaction?

How quickly do the signs and symptoms appear after exposure to foods?

What is your protocol if an exposure happens?

Do you travel with medicine?

Any required information for the Imiloa team?

Additional notes you want to add

Emergency contact name and phone number(Required)

I have read and agreed to the terms at Imiloa Institute Terms & Conditions Agreement .

Special requests or notes for our team

If you are planning to travel with someone, what is their name?

If you've registered for a shared room and want us to pair you with someone, what does your roommate need to know about you?

(e.g., I snore. I get night terrors. I sleep eat.)

Are you a Bewildered podcast listener? If so, what do you like about the podcast?

What do you feel is the main obstacle in your life right now that is preventing you from being your most pure wild self?

So that we’re all on the same page…

Thank you for taking the time to answer these questions. We look forward to reviewing your form, and we can’t wait to meet your pure wild self in Costa Rica!

reTREAT INTAKE FORM