Plant Retreat Registration Form

Plant Retreat Registration Form

A Yoga+Plant Medicine Leadership Retreat by Kali-Prana Yoga Collective
Participate Information
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Have you practiced Yoga before?
Have you taken psilocybin before?
Do you have experience with Hape?
If yes, what type of yoga have you practiced?
Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)
What is your experience with plant medicine (Psilocybin, Hape, and Cacao) in particular?
What you ever had a challenging experience with psilocybin? Other psychedelics?
MaleFemaleOther
Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.
Do you have an allergies?
Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)
What inspired you to join to this retreat?
Deposit & Payment

The total cost of this retreat is $1400. Your spot is secured through completion of this form and a $250 deposit payable to Angela Foster via Venmo/Paypal
I understand that this retreat total is $1600 and will be paid in full by August 19th, 2025?
Have you paid your deposit of $250?
Do you need a payment plan?
Do you perfer venmo or paypayl?
What is your venmo or paypal handle?
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:

As I participate in activities offered by the hosts and special guests, I understand that the offerings of this retreat are not a substitute for medical attention, examination, diagnosis, or treatment.

I will receive fitness related information and instruction. I recognize that all exercise programs require physical exertion that may be strenuous and may cause physical injury and I am fully aware of the risks and hazards.

If at any time during the activities I feel discomfort or pain, I will inform and seek assistance from the guides.

I may rest at any time during the activities and throughout the duration of the retreat. I will listen to my body and respect its limits on any given day. I will council my guides as well in moments of question.

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any activity program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my participation in fitness classes or workshops.

I recognize that it is my responsibility to notify my guides of any serious illness or injury before every class.

I accept that neither the instructors, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this reatreat.

I understand that the $250 deposit for the retreat is final with no refunds and the balance of my payment is due by August 19th, 2025. Cancellation fees will apply due to associated costs such as the catering service, accomodations, special guests, swag etc. I agree that all cancellations made less than three weeks in advance of the retreat be paid in full and that I may transfer my spot to another person.

Exclusion of Participation: In the unfortunate circumstance, if a guest conceals physical and/or health issues, is unfit, and/or causes disruptions that endanger the provision of the service and/or the health of other participants,facilitators, or equipment the guest can be excluded from the participation of the Retreat after an initial warning. If the situation arises, the contract will be terminated without further notice, already paid costs are non-refundable and incurring costs are to be paid by the guest.

I have read the above release and waiver of liability and fully understand it’s contents as well as the Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above.
Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Plant Retreat Registration Form

Deposit & Payment