NSR JULY 2023

Nervous System Rewire Retreat

July 9th - 16th, 2023
Please answer all questions:
Name*

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Please confirm that you are 21 years old or older by the start date of the Retreat:*

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Gender*

FemaleMaleNon-binary/third genderOther
Have you ever visited Bali before, and if so for what purpose e.g volunteering, vacation?*
How do you heard about this retreat? Please tick below:*

The Yoga Barn poster or postcardThe Yoga Barn websiteThe Yoga Barn newsletterYoga Barn class with TinaYoga Barn workshop with TinaBalispirit.com websiteBalispirit.com newsletterHELD websiteHELD newsletterSchool of Sacred Arts (SOSA)Yoga JournalFacebookInstagramReferralOther
All answers are strictly confidential and will not be shared with anyone else.
Medical Declaration
We require you to complete this Medical Declaration form due to the physical and emotional nature of yoga and related activities, if you fail to complete this declaration, you will be unable to attend the retreat.

The information you provide in this Medical Declaration confirms that you are in good health and that there are no medical reasons why you should not partake in this retreat.

The information provided will be treated with the strictest of confidence and will only be available to those who will be delivering Training activities to you. We will not share the information contained within with any other person except with your express consent. For legal and insurance purposes we will retain this information for a period of 3 years from the end of the retreat, and this information will be stored securely.
Pease note, this information is vital & mandatory.

Providing accurate information here assists us in ensuring you remain protected, healthy and as safe as possible.

If you are currently under medical supervision for any reason, or have recently suffered an injury, operation, are pregnant, or have ever been under hospitalized psychiatric care, you must provide a doctors letter or certificate confirming that your medical representative permisses you to take part in the retreat.
Emergency Contact Name:*

First NameLast Name
Emergency Contact Relationship:*
Emergency Contact Email:*
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Emergency Contact Number:*

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Doctors Name:*

First NameLast Name
Doctors Phone Number:*

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Doctors Email:*
example@example.com
Have you ever experienced or been diagnosed with any of the following conditions?(Please check all that apply)*

ADHDAllergiesArthritisAnxietyAsthmaAnemiaAutoimmuneBack problemsBi-PolarBorderline Personality DisorderBroken bonesCancerCarpal tunnel syndromeCrampsChronic FatigueC-PTSDDepressionDetached RetinaDiabetesDisabilityEpilepsyFracturesHeadachesHearing disorderHeart problemsHigh blood pressureHyperthyroidKnee problemsLow blood pressure/faintingLearning disorderMental health disorderMiscarriageNeck problemsOperationsOsteoporosisPanic AttacksPersonality DisorderPTSDPsychosisPregnancySeizuresSprainsStrokeStressSuicide AttemptedSuicidal ThoughtsVertigoVisual impairmentThrombosisUlcersNoneOther
If you checked any of the conditions above, please give details of when, duration and current status of the condition:*
Have you ever had injuries, or experienced any problems or damage to your:(Please check all that apply)*

ArmsAnklesCoccyxHeadHipsJointsKneesNeckSpineShouldersSacrumTendonsWristsNoneOther
If you checked any of the conditions above, please give details of your experience and current status of the condition:*
If you are currently under a prescription for any medications, inhalers or homeopathic treatments, please describe the prescription, dose and reason:
If you have had any operations (including birth or abortion) please provide details below, including when and outcome of surgery:
If you are currently using any recreational drugs, or substances including tobacco/cigarettes, please describe them and the frequency of use:
Do you have any current medical or physical condition that may affect your participation in this teacher training? If so, please indicate the condition thoroughly below:*
Please list any previous mental health history, including treatment/medication for conditions such as depression, anxiety, panic attacks, etc:*
Do you have any current physical, mental, or emotional challenges that could possibly be an issue during the retreat? (It is important that we are fully informed of such challenges prior to the retreat). Please be thorough & list in detail:*
Please provide a short history of your past traumas, including the age when it occurred, e.g. 0 yrs mother smoked while pregnant, 0 - 3 yrs parents left me alone to cry, 5 yrs, family home burned down, 12 yrs fell off trampoline and broke arm, 26 yrs date rape at college, 34 years divorce and left abusive marriage:
I take full responsibility for my health during the retreat. I will inform you of any medical changes. I understand that the retreat includes physical movements, and that as is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that the instructions given throughout the sessions are intended as guidance only. I understand that while all due care will be taken by the teacher, they cannot be held responsible for my improper practice at any time. To ensure that no personal injury occurs, I agree to adjust my practice according to my limitations and the decision to perform any yoga postures remains mine. I declare that I will take full responsibility for myself during the retreat.*

I agree
I agree that I will email you regarding any new medical issues that arise prior to the retreat commencement date and after completion of this Medical Declaration.*

I agree
I confirm that all information provided above is correct and up to date to the best of my knowledge.*

I confirm
REGISTRATION
- Rates are listed in USD.
- The rates do not include flight, accommodation, visa, and transportation in Ubud, Bali.
INVESTMENT:
- Deluxe Ensuite $1995.00 USD
- Taj Twin $1785.00 USD
- Lumbung Single $1825.00 USD
- Lumbung Twin $1785.00 USD
- Little Sweet $1900.00 USD
REFUND POLICY:
- Payment less a $500 deposit will be refunded in full 2 months ++ out from retreat commencement.
- 50% Payment (less $500 deposit) will be refunded 4 weeks out from the retreat.
- No refunds will be made within 4 weeks of the retreat.
I understand that,

All rates are listed in USDFull refund given only in the unlikely event the program is canceled by HELD.Travelers Insurance is recommended.
Commitment:

In submitting this application form,
- You agree to commit to 100% class attendance during the retreat, without exception.
- You agree to be 100% punctual & arrive to class 5-10mins before each lecture/practice, to arrive, settle & ground before each class begins.
- You agree to conduct yourself in a respectful manner towards your teachers, your fellow classmates and the studio staff.
- You agree to abide by the payment policy : $500 non-refundable deposit paid upon initial registration, closing date for full payment is 1 month prior to commencement of training.
- You have read and understood that you are attending this retreat as an intensive immersion, & as such, you will devote your time and energies to give full priority to this training, practicing self-responsibility, ownership of your emotions, thoughts, and actions, consistent engagement in self-study and self-awareness, and open contribution to the overall group experience.
- You understand that you are required to fulfill the above obligations, to the satisfaction of the director and staff, in order to remain on the course, and that tuition payment alone does not guarantee certification from HELD. Punctuality, full participation, completing assessments & acting in a respectful manner of integral conduct will insure certification & successful completion of the training.
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Nervous System Rewire Retreat

Medical Declaration