Gather the Women

Participant Information

Name*

First NameLast Name

Birth Date

MonthDayYear

E-mail

Cell Number

Area CodePhone Number

Which phase of Womanhood are you in?

MaidenMotherCroneOther

What is calling you to Gather the Women at this time?

Do you have any experience participating in retreats, women’s circles, ceremonies or sacred movement practices?

This gathering includes a tobacco pipe ceremony in optional ceremonies. Are you comfortable being in a space where tobacco is used in a prayerful ritual?

YesNoUnsure - Would like to learn more

The land we gather on is a working farm with limited bathing facilities. Are you comfortable with rustic accommodations?

YesNoMaybe - Tell me more

Do you have any dietary restrictions, allergies, or important food preferences we should be aware of?

This is a sacred space of reverence, ritual, and sisterhood. Are you willing to honor the ceremonies, rhythms, and guidelines set for the weekends

YesNoI have questions

What type of accommodations would you prefer?

I’m interesting in co-housing with other women in a nearby air bnb (extra fee of $40)I’ll find my own accommodations (I’ll stay offsite)I’ll bring my own tent and bedding

This retreat will be a cellphone-free zone (except for emergencies). Are you willing to keep your phone off or tucked away during the gathering?

YesNoI have questions

How did you hear about this gathering?

Is there anything else you’d like to share with us or anything you need in order to feel fully supported during the retreat?

Ceremonial Safety, Participation, Liability & Photo Release

By joining Gather the Women, you agree to participate with personal responsibility, reverence for the space, and care for the collective. This is a ceremonial retreat involving optional movement, breathwork, yoni steaming, plant medicine, and emotional release. The gathering takes place on rural farm land with outdoor bathrooms and limited modern amenities.

You understand and agree to the following:

• All activities are voluntary and should be entered into at your own pace

• Sacred tobacco may be used in optional, prayerful ceremony

• No alcohol or recreational substances are permitted on site

• You are responsible for your personal safety, emotional well-being, and belongings

• You will disclose any medical conditions, allergies, or dietary needs in advance

• This is a phone-free space to honor presence and connection.

Medical Release & Liability Waiver

By attending, you agree to assume full responsibility for your physical and emotional health during the retreat and release the facilitators, collaborators, and landholders from any liability related to injury, illness, or emotional distress that may arise. You affirm that you are participating by choice, and that you will honor your body and boundaries throughout.

Photo & Media Release

Photographs may be taken throughout the retreat to honor the space and share the spirit of this gathering with future circles. By signing, you grant permission for your image to be used in photos or videos for promotional or archival purposes. If you prefer not to be photographed, you may opt out by checking the box below or speaking directly with the facilitators—we will fully honor your wishes.

By signing below (or submitting this form), you agree to these terms and enter into this container with integrity, consent, and care.

Do you give permission to be photographed and/or filmed during the retreat for promotional or archival purposes?

Yes, I give my permissionNo, I prefer not to be photographed or filmed and will let facilitators knowI’d like to talk more before deciding

Emergency Contact's Name

First NameLast Name

Emergency Information

Relationship

Phone Number

Area CodePhone Number

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Alt. Phone Number

Area CodePhone Number

Gather The Women

Payment: Please complete your registration by sending your selected amount using one of the following options:

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