Healing Center and Program

* All fields with an asterisk beside are required to be filled out. Please double-check all your responses before submitting them.

Your full name (“legal” or spiritual name, whichever name people usually call you). *

Your Email (we recommend using protonmail.com to keep emails confidential) *

Your Age *

Your Height *

Even though Ecuador is a Spanish-speaking place, understand that everyone who stays at Peaceful Village speaks at least basic English. How proficient are you at speaking and reading the English language? Do you also speak or write in other languages? Would you be able to help with translation from English to another language? *

Describe all your health issues (physical or emotion ones) and how long you’ve lived with them. *

Are you allergic to any foods or fruits? *

Did you ever try any natural cures or approaches in the past or did you take only the allopathic way? *

Are you taking any pharmaceutical medications or supplements at the moment and for how long have you been taking them? (pleae give exact names and if you know, the company who manufacturers it or is on the label). *

Do you have any recent serious physical injuries, wounds or surgeries? *

What is your current diet? What do you usually eat on a daily basis? *

If we are able to make a specific healing plan and program for you, are you willing to stay on it long-term? Realize that this is a lifestye change that stays with us for life. If you go back to your old habbits, old health issues come back. *

If you are accepted to come, how long can you stay at Peaceful Village Raw Vegan Healing Community as a healing guest? *

How much money (minimum donation amount) are you willing to invest in your physical/emotional health in Peaceful Village Raw Vegan Healing Community? *

How desperate or eager are you to overcome your suffering and health issues? *

If you have the opportunity to openly share your physical/emotional health issues with a small group of people here, would you be able to easily? *

Would you like to become a future community member and get a plot of land in our community? *

Would you be arriving by yourself or with company? How many people and who? *

What type of accommodations would you prefer to stay in: a well-equipped 1 – 2 person tent in a small camping area, private bedroom or attached room, private cabin (with private bathroom) or private cabin (with use of outhouse)? *

What are your feelings about nudity and allowing people to be nude at Peaceful Village? *

What are your favourite fruits, vegetables, herbs, and other plants? What foods do you not enjoy? *

Please tell us more about yourself. *

Have you already purchased plane/bus/train tickets to Ecuador, or are you currently already in Ecuador? If so, when do you plan to visit (from which start date to which end date)? *

How did you find out about Peaceful Village Raw Vegan Healing Community? *

Please provide full URLs to any social media profiles/contact information (Facebook, MeWe, YouTube, BitChute, Instagram, WhatsApp, etc.) or your websites. *

Do you have any questions or feedback? *

Would you like to register for our free email newsletter? *
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I have read and agree to the Waiver and Release Form. I will sign the form if I am accepted and when I arrive at Peaceful Village. *

I have entirely read what is written on this page and this website thoroughly, and agree. *

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