ISTA Participant Application FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 3Legal Name *FirstLastName commonly usedFacebook NameFacebook URLEmail *Phone / WhatsApp *Residential Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryNationality *Date of Birth *NextGender at Birth *FemaleMaleOtherGender Identification *Emergency Contact Name *Emergency Contact Phone Number *Dietary Requirements (If Any): *VegetarianVeganPescatarianNo specific requirementsAllergies (If Any): *Will you be flying in from overseas? *YesNoIf 'yes' above, what airport / country will you be flying from?How will you be travelling to the venueCarPublic TransportTaxi/ShuttleOtherHave you attended an ISTA seminar before?First timeSecond timeThird time or moreAre you attending with a partner? *YesNoIf 'yes', Who?Why have you decided to register for this training?Referred byNextWhat do you want to gain from participating in the Spiritual Sexual Shamanic Experience (SSSEX)?What previous events, if any, have you attended that explored the topics of healing, tantra, sexuality, breath-work, spirituality, and/or meditation?What forms of personal growth work have you undertaken in your life? (therapy, seminars, yogic training, etc.)What experience do you have (if any) receiving your own sexual healing work?Please share any recent major life events--deaths, break ups, trauma, business/career changes or other emotional transitions. If you are not sure whether to include something, we ask that you share it here, as this type of information helps us to hold a better container for our students as they move through this work.Do you currently work in the field of sexual healing or sex education? If not is it something you may want to do in the future? If you are interested working in this field, what experience do you have (if any) as a practitioner of other modalities of healing work?Physicality - The training includes some physically active components ie: dancing & full body movement. Please let us know if this will present any physical difficulties for you:YesNoPlease Detail:Health - Please tell us about any health issues and/or infectious diseases you may have. Please also tell us if you are on medication of any kind (please specify):YesNoPlease Detail:Mental Health - Please indicate below if you have any history of psychiatric treatments or if you are currently taking any psychiatric medication:YesNoPlease Detail: Agreement: "I agree to take full responsibility for the nature of my experience. As an adult, I agree to be responsible and respectful in my interactions with others. I will use clear direct verbal communications and if I am not comfortable with something, I will express my concerns clearly and directly to the facilitators and organizer. I agree to monitor my participation and not exceed my own physical and emotional limits and I assume all risk for my condition in this workshop. I acknowledge that I assume all risk from any consequences due to any pre-existing physical or psychological conditions that I have."AgreeDisagreeI have read and agree to the above text: *Submit
