Relieve HER Retreat Registration Form

Guest Information

Name

First NameLast Name

Birthdate

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.

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.)

Are you pregnant or is there any possibility of being pregnant? If Yes, please indicate your due date

Date

Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.

Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)

What inspired you to come to this retreat?

Signature

Date Signed

Date

My Products

Registration Fee Double Occupancy

1 Guest

Shared Room

$175.00 Quantity
Item subtotal:$0.00

Registration Fee Single/Private Room

1 Guest

Single/Private Room

$275.00 Quantity
Item subtotal:$0.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Afterpay

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.

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

I may rest at any time during the retreat and over the weekend. I will listen to my body and respect its limits on any given day.

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 hosts of any serious illness or injury before every class.

I accept that neither the hosts, 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 registration fee for the retreat is final with no refunds and that my flights are NOT included. I understand that it is my responsibility to make travel arrangements to and from the designated retreat site. Shuttle service is provided to and from the local airports upon arrival & departure. Cancellation fees will apply due to associated costs such as the catering service, accomodations, special guests, swag etc. I agree that all cancellations made will result in the forfeiture of my registration fee, however 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.

Media Waiver Disclaimer:

By signing this document, I agree to allow "Revive Collective LLC. DBA Revive HER Retreats" to photograph & video me during the retreat for marketing purposes. Furthermore, I authorize "Revive Collective LLC. DBA Revive HER Retreats" to use these collected images, videos, etc and release the company and it's subsidaries from any liability or penalties from the usage of such media.

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.