Retreat Registration Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail

example@example.com

How did you hear about us?*

Other*

Emergency Contact: Name/Relationship to you/Contact Number*

Do you have any of the following conditions that may prevent you from participating in or could be affected by Physical activity? (Please tick all that apply)*

If you ticked any of the above please give details below:

Have you had any recent injuries. If yes please state what and when it happened:*

Have you had any recent operations? If yes please state below including dates.*

Participant Declaration:

Please read the information and sign the declaration below. If you are under 16 years old, a parent/ guardian or care provider must also sign this form.

If you have reported any of the health conditions above or experience any changes to your health, please, inform us and contact your GP for advice.

Liability Waiver. Participants take full responsibility for their own health and any illness or injury that may occur. Participants cannot and will not hold instructors or any employers or affiliates responsible in the case of accident or illness during practice. The instrucors and organisers accept no liability for any loss or damage to personal belonings you bring with you, which extend to any damage to motor vehicles and their contents. These are left at the participants own risk.

Photographs and video footage will be taken during classes and at other times during the day for promotional material and publication on social media and our websites. By signing this declaration you consent to being included in any photographs and video footage. If you wish to opt out please tick the box below.

48 Hour Cancellation / Change Policy. Attendance can be rescheduled without charge, provided a minimum of 48 hours advanced notice is given. If less than 48 hours, then payment will not be refundable.

Declaration:

I confirm that I have read the above and agree to the terms and agreements stated above. I agree that where any medical condition, discomfort or injury which may be affected by physical activity applies or becomes applicable whilst participating in the activities, I am responsible for informing the instructors and consulting with my Doctor.

I do not wish to be included in any photographs or video footage.

Please tick if you DO NOT wish to be included in photographs or video footage.

Signature

Date

Spring Retreat Participation Form: