Retreat Readiness Application & Deposit
Please submit this completed form along with your deposit to confirm your retreat. If there are any issues in your responses to this form that require further conversation about the appropriateness of this retreat, I will contact you to discuss.
SUMITTAL OPTIONS:
- EMAIL: (Cut/Copy THIS ENTIRE PAGE into Word.doc or directly into your Email program and Email to Ronda) OR....
- Print & Snail Mail or Fax: Ronda LaRue; OjaiSoulArts; 703 Tico Rd; Ojai, CA 93023 FAX:805-650-3077
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APPLICATION For CONFIRMATION FORM:
Please complete EACH question below and email or snail mail back to me as soon as possible to confirm your participation. You are not confirmed and enrolled until this form and your deposit are completed.
I. CONTACT INFORMATION:
1) Name (Full Name AND nickname as you wish to be addressed):
2) Your PRIMARY email address:
3) Your HOME or Office Phone:
4) Your CELL Phone (important for travel days!):
5) Your Mailing Address:
6) Emergency Contact Person:
7) Emergency Contact Phone:
II. LIFESTYLE PROFILE
1) Gender:
2) Current Age:
3) Occupation:
4) Marital Status/# In Your Household:
PLEASE KEEP THESE NEXT RESPONSES AS BREIF AS POSSIBLE....
5) What do you do for exercise and how often?
6) How healthy would you say your diet is on a scale of 1-10 (10 being EXCELLENT!):
7) Do you eat meat...or are you strictly vegetarian or vegan; any dietary restrictions or allergies?
8) Do you struggle with any addictions? (alcohol, work, TV, sugar, caffeine, etc.):
9) What do you do as spiritual practice(s)?
10) What are some areas of spirituality that most interest you or that you'd like to make more a part of your daily life?
11) What is your physical fitness level ... Any restrictions of movement?
12) Have you had any significant training (spiritual or other) that you would like me to know about?
13) Are you happy with your life direction? Why or why not (stay brief please):
14) What do you hope to gain from this retreat?
15) How "good" are you at going with the flow on a scale of 1-10 (10 being EXTREMELY GOOD):
16) When you don't get your own way in something or are uncomfortable in a situation, you most usually ____________________________ (be honest and fill in the blank):
17) What most frustrates you in life at present?
18) What do you most enjoy about your life at present?
III. MEDICAL PROFILE:
1) Are you under the care of a physician or mental health care provider for any current condition that you feel might impact your own (or others) safety or wellbeing at this retreat?
1 a) If so, please explain briefly (Be sure to discuss participation in this retreat with your practitioner if/as warranted to assure your own wellbeing):
2)Are there any physical conditions, medications, or emotional issues (addictions, abuses, anxiety/depression disorders etc.) that you feel may compromise your healthy participation in this retreat or the welfare of others?
2 a) If so, please explain clearly and be sure to discuss and obtain agreement with me and with your health care practitioner before confirming your attendance.
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IV. PARTICIPANT RELEASE AGREEMENT: Completing this form and returning it to Ronda LaRue constitutes agreement and acceptance of the following release of liability and self-responsible retreat: Please be sure you are informed. By completing and returning this form, I (registrant named above), agree that the above confidential information is accurate and complete to the best of my knowledge. I further understand that failure to disclose information could affect the safety and wellbeing or myself or others around me and I agree to hold Ronda LaRue and OjaiSoulArts harmless for any such conditions or repercussions. I understand that this work is strictly taken up at my own risk and responsibility. I understand that the nature of this retreat is not medical or therapeutic and any advice, suggestions or practices are for me (registrant), to decide upon within myself. In the process of making this application, I have considered my conditions (mind/body/spirit) and my readiness, so that by submitting this form, I (registrant) release Ronda LaRue and OjaiSoulArts from any loss, damage or injury to my person or property as a result of attending this retreat including past, present or future repercussions. I certify by submitting this Application for Confirmation Form that I am physically, mentally, and emotionally capable of participating in this program and that I take full self-responsibility for any rigors or dangers inherent in such undertaking.
Cancellation: In the event of cancellation , I understand that airfare/travel is nonrefundable at anytime. I understand that my deposit is non-refundable unless Ronda LaRue is able to find a replacement for your spot in which case up to 70% may be refunded (depending upon extent of admin. time utilized), or if I for any reason Ronda LaRue finds it necessary to cancel your retreat, in which case 90% will be refunded. Full retreat balance is due 30 days prior unless other arrangements are made. Client remains obligated to pay 80% of full retreat amount if he/she cancels within 3 weeks of retreat and I cannot refill his or her space. (SEE optional TRIP INSURANCE OPTIONS BELOW)
DID YOU KNOW YOU CAN INSURE YOUR TRIP IN THE EVENT OF NECESSARY CANCELLATION? For those who would like to insure your retreat trip with a cancellation policy, I am told this online site is good to work with: insuremytrip.com (have had Access America and Travel Guard recommended but no personal experience or connection with them.)
INFORMED CONSENT: Returning /submitting this form constitutes agreement and acceptance of the release and self-responsibility for this work as posted on this webpage and not by any other delivery form that may be intentionally or unintentionally (realized or not) altered. If you find that you are not willing to agree and assume your own self-responsibility per this release, then please do not submit or return this completed form, and (if your deposit has already been made) email in writing to let me know you are not agreeing to comply and you will be refuned per our policy and you will not be enrolled in this retreat.
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PLEASE CUT/COPY (into Word.doc or straight into your Email) ...OR Print and Fax or Snail Mail your completed form here. Ronda LaRue 703 Tico Road Ojai CA 93023
Sorry we live in a culture that requires this kind of legalize to take back our own power and rightful self-responsibility...but, sadly, we do.
....NOW! WELCOME! AND I LOOK FORWARD TO GETTING STARTED ON THIS GRAND ADVENTURE TOGETHER!