Rebirth Winter Retreat Registration Form 2020-21

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We need to know a few things about you. Our intention is to make the experience safe and inclusive where possible, and you are responsible for our own experience and safety. Please all fill out the form below. All held in strict confidence.

Please state the amount you have paid will pay for the retreat

Name *

Address *

Email: *

Phone No. *

Next of kin contact info: *

Do you have any prior experience with personal growth and movement practice? Please say something about that. *

Have you in the past or are you currently taking any form of medication? *

Do you have any physical, emotional or mental health issues that would be useful for us to know about? *

Please say something about why you are thinking of coming to this retreat. *

What support/resources will help you integrate when you return home? *

Please confirm by ticking below that you understand that you are responsible for your own safety and wellbeing when attending this retreat *

I understand that I am responsible for myself

Required

Coronavirus

Have you had any Coronavirus / Covid-19 type symptoms in the last 14 days ? (high temperature / a new continuous cough / a loss of, or change to, your sense of smell or taste.

Yes

Clear selection

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or who has Corona-virus /Covid-19 - type symptoms ?

Yes

Clear selection

Have you been told to stay at home, self-isolate or self-quarantine ?

Yes

Clear selection

Do you or anyone that you live with fall into the ‘clinically vulnerable’ or ‘clinically extremely vulnerable’ categories as defined by the NHS? If you are not sure please visit https://digital.nhs.uk/coronavirus/shielded-patient-list

Yes

Clear selection

Do you agree to comply with the preventative measures we have put in place to reduce the risk of the spread of Coronavirus / Covid-19. (Please see document sent in email with the link to this questionnaire)

Yes

Clear selection

By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate to the best of your knowledge.

Submit

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