CTS Wilderness Liability Waiver
Wilderness programs combine therapy and skill building through experiences in an outdoor environment to kinetically engage clients on cognitive, affective, and behavioral levels to create long term changes, create positive relationships, and increase self-worth.
Client Information
Full Name
Date of Birth (MM/DD/YYYY)
Medicaid # (if applicable)
If Minor, Parental/Guardian Information
Full Name
Phone number
Email Address
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which wilderness program are you registering for?
September 13th, 9am-12pm
October 11th, 9am-12pm
November 15th, 9am-12pm
Where did you learn about this program?
What do you hope to gain from this program?
Anything that is important for us to know?
Acknowledgement of Photo Release: I grant permission to Collaborative Trauma Solutions, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child while at Collaborative Trauma Solutions Wilderness Retreat for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Collaborative Trauma Solutions. I hereby release Collaborative Trauma Solutions and its legal representatives from liability for any violation or claims relating to said images or video. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Over the Counter Medication Release I grant permission for Collaborative Trauma Solutions to provide Non-prescription medications, or over the counter (OTC) medications (such as acetaminophen, ibuprofen, antacid, Benadryl, and melatonin) may be administered with written permission through a signature below from parents/guardians. All OTC medications will be in the original packaging and given as recommended as on the bottle.
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USD
$120 per person, per outing for Wild Women Reflection. $275 per person, per outing for Teen Wilderness.
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Please sign if in agreement for Collaborative Trauma Solutions Liability Form
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