Summer Coastal Retreat / August 2-4, 2019 Participant Information & Waiver Form
Please fill out the form below. Your electronic signature at the end of this form completes the waiver.
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General Contact Information
Full Name
Year of Birth
Address
Email
Phone #
Emergency Contact (Name & Phone)
How did you hear about this retreat?
Personal Information
The following information is strictly for the confidential use of the retreat leaders. Please answer these questions fully to enable the teachers to guide you appropriately.
Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, supine, walking or movement practice?
Are you currently experiencing (or have you recently experienced) any significant mental health issues (e.g. depression, eating disorders, anxiety, drug/alcohol abuse)? If yes, please give details of condition(s) and date(s).
Are you taking any medication for any physical or psychological condition? If yes, please give details of condition(s) and medication(s).
Describe any present circumstances that might place you under additional stress or may significantly affect your yoga and/or meditation practice (e.g. bereavement, loss of work, relationship breakdown, etc.)
Do you have any special dietary needs? Please provide relevant details.
Is there any additional information you would like to convey to the retreat leaders?
Waiver
Yoga and meditation are generally considered safe, healthy and beneficial practices. However, when practiced over time they often lead to self-study, which can sometimes bring about emotional discomfort. If you have a history of mental health illness, have endured recent trauma or have any concerns check with your health care provider about whether or this retreat is appropriate for you at this time.

I hereby release Ashley Dahl, OpenSpace Mindfulness, Carol Grimes, North Fork 53, and all sponsoring agencies from responsibility for any injuries I may receive as a result of participation in this retreat. I certify that my level of physical and emotional condition determined by myself or my physician will allow me to safely participate in this program. I further state that I have read and understand this waiver and that I am legally competent to sign this.
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