Confidential Weekend Retreat Registration

Confidential Weekend Retreat Registration

For 2-3 day workshops/retreats
Name*

First NameLast Name
What is the name or nickname you prefer to be called?*
If you identify as non-binary, please indicate your preferred pronouns here.
Where do you live?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of birth*

MonthDayYear
Date
E-mail*
Phone Number*

Area CodePhone Number
Relationship Status*
Occupation*
Emergency Contact Name*

First NameLast Name
Emergency Contact relationship to you*
Emergency Contact phone (cell preferred)*

Area CodePhone Number
How did you hear about this workshop?*
If other, please specify

What is your level of experience with sexual healing work (workshops, trainings, and/or private sessions)?*

	1	2	3	4	5	6	7	8	9	10

1 is No experience, 10 is Lots of experience

Please indicate your level of familiarity with the chakra system. *

	1	2	3	4	5	6	7	8	9	10

1 is Not at all familiar, 10 is An expert

What do you wish to receive from this workshop? (It's fine to not know and be open to infinite possibilities!)*
Are you willing to show up and simply receive rather than coming as a "healer," "helper," "teacher," or"giver"?*
What are your passions, dreams, and deepest desires in life?*
Do you have any health issues (mental, emotional, or physical) that would affect your participation in the workshop? (please describe so we can best support you)*
Do you have (or suspect you have) a history of sexual trauma?*
Meals at San Damiano are buffet style. Special meals can be prepared for Vegetarian, Vegan, and Gluten Free. (select one option if you need a special meal preparation)

VegetarianVeganGluten Free
How do you prefer to eat? (select 1)*

OmnivoreLacto-Ovo Vegetarian (eggs/dairy okay)Ovo-Vegetarian (eggs okay)Vegetarian (no eggs or dairy)VeganOther
Food sensitivities (select as many as apply)*

Gluten-freeDairy-freeSugar-freeOther
Do you have any food allergies? (You are welcome to bring supplementary snacks.)*
Anything else you would like to share with us, or that it would be helpful for us to know?
By submitting this form, I agree to attend the workshop as a participant and allow myself to receive. We know how challenging this can be for most women as it requires surrender. I understand that the workshop I will be participating in is provided for the purpose of healing, releasing, awakening, and reclaiming wholeness.

I further understand that the workshop should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that the facilitators, assistants, and other retreat staff are not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the workshop should be construed as such. I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the facilitators updated as to any changes in my profile and understand that there shall be no liability on the part of the facilitators for any reason whatsoever.
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