A Safe Space Mentor Retreat Registration 
A Safe Space Mentor Retreat Application 2023-2024
Contact us :  asafespacementorship@gmail.com 
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Name *
Which Retreat Are you applying for  *
Pronouns  *
Email *
Phone *
Emergency Contact Name *
Emergency Contact Phone  *
Date of Birth  *
Current Location *
Social Media Handle *
Would you be willing to jump on a zoom call before retreat as a part of our vetting process? *
Dietary restrictions *

Why would a wellness retreat be beneficial for you?

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What does self-care mean to you?

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What makes you happy?

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What are somethings you want to improve on in life?

 *

What does honesty mean to you?

 *

What does the word “family” mean to you?

 *

Are you diagnosed with any mental health condition?

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Are you diagnosed with any physical health conditions?

 *

Do you have any triggers?

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Anything else you want to share?

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I give A SAFE SAPCE MENTORSHIP permission to use my images and any content taken during the duration of the retreat for any press media, or public advertisment in relation to the mission of A SAFE SPACE MENTORSHIP and its partners/sponsors . I recognize this program includes, but is not limited to, certain physical activities, which may pose some risk of injury. I further understand and agree that A SAFE SAPCE MENTORSHIP is not an insurer nor is responsible for any costs incurred by me arising from activities conducted within the scope of this program.I indemnify and hold harmless A SAFE SAPCE MENTORSHIP and any of its employees and/or agents from all claims from my use of A SAFE SAPCE MENTORSHIP property or participation in any programs. I will further indemnify and hold harmless A SAFE SAPCE MENTORSHIP its employees, partners, sponsers and/or agents from all costs, expenses and liabilities resulting from any claim brought from my  use of A SAFE SAPCE MENTORSHIP property and/or participation in A SAFE SAPCE MENTORSHIP programs to the extent of the A SAFE SAPCE MENTORSHIP retreats liability under general law.
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