ROP Women's Wisdom Quest Registration

Women's Wisdom Quest Enrollment

P.O. Box 57 • Sandpoint, ID 83864 • (208) 217-5788 • www.ritesofpassagesandpoint.com
To register for the Women's Wisdom Quest program, please fill out this form, sign the waiver.
Participant Information
Participant Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Do you have any access or accommodation needs you'd like us to be aware of?
What intentions or wishes do you have for your participation in the Women's Wisdom Quest? What is important for your guides to know about you?
Confidential Health Questionnaire: Have you had any debilitating illness, surguries or major injuries in the past 20 years?
Confidential Health Questionnaire: Please list current and history of Allergies. Have you ever had anaphylaxis when exposed to insects/food/medicine? Do you carry an epi pen?
Confidential Health Questionnaire: What medications are you currently taking? What conditions are they treating?
Confidential Health Questionnaire: What physical conditions are currently limiting in your daily lifestyle, and how will this impact your 9 day nature immersion?
Confidential Health Questionnaire: In the past 10 years, are you working with any mental health specialists? Please share any resources or challenges that are current in your emotional/mental/physcial wellbeing.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Waiver
PARTICIPANT RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS
ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

Please read and be certain you understand the implications of signing.
Express Assumption of Risk Associated with Wilderness Rites of Passage.
I, Name of Participant do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with wilderness Rites of Passage Sandpoint, DBA Mother Element LLC. Inherent hazards and risks of outdoor activities include, but are not limited to:

1. Risk of injury or death from exposure to flora and fauna in the wilderness.
2. Exposure to the elements and temperature extremes which may result in heat
exhaustion, heat stroke, sunburn, hypothermia and dehydration, inclement
weather, thunder and lightning, severe and/or varied wind, temperature and other
weather conditions.

*I understand the description of these risks is not complete and unknown or
unanticipated risks may result in injury or illness.

Release of Liability, Waiver of Claims and Indemnity Agreement
In consideration for being permitted to participate in the above described activity(ies) and related activities I HEREBY AGREE THAT I, MY SPOUSE, MY ASSIGNEES, HEIRS, GUARDIANS AND LEGAL REPRESENTATIVES WILL NOT MAKE A CLAIM AGAINST OR SUE Rites of Passage Sandpoint, DBA Mother Element LLC ON ACCOUNT OF ANY AND ALL INJURY, or loss or damage to person or property, RESULTING FROM THE NEGLIGENCE OR OTHER ACTS, HOWSOEVER CAUSED BY Rites of Passage Sandpoint, DBA Mother Element LLC.
This release shall by binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK
AGREEMENT, I FULLY UNDERSTAND ITS TERMS.
Signature
Today's Date

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2 digit month, 2 digit day, 4 digit yearDate
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Women's Wisdom Quest Enrollment

Participant Information

Waiver