Name *

First Name

Last Name

What services are you interested in receiving a schalorship for? *

Wellness Sabbatical

Wellness Day Retreat

Rituel Ceremonies

Group Immersions

Other (please specify below, what you have in mind)

What is your annual household income? *

Under 25k

Between 25k-50k

Between 50k-100k

Between 100k -250k

250K +

By checking the box below I acknowledge that all information provided in this application is honest, accurate, and true. I understand that any false statements may disqualify me from consideration for the scholarship.

Yes, I certify all information provided is accurate and honest to the best of my knowledge.