Allergies and Dietary Needs
Please indicate and list any allergies, injuries/conditions, dietary restrictions (ex. vegan, gluten free), etc. or NA
Is there anything you’d like to share with us that was not asked? Alternately, is there anything that we can assist you with before the immersion?
Emergency Contact Information
Emergency Contact Name
* Emergency Contact Name
Relationship between you and the Emergency Contact
Emergency Contact Phone Number
* Emergency Contact Phone Number
Emergency Contact Email Address
During the Immersion, we will be offering two optional experiences. These experiences are not included in the cost and are a separate expense to you.
ZIPLINING AND LOCAL LUNCH The cost for the Ziplining experience is $65.00 This cost must be collected by November 1st and can be paid via PayPal. LUNCH You are responsible for paying for lunch at the time of service. The ziplining experience is designed to take the work you will be doing to a deeper level. Essentially, it is a fun and thrilling way to face fears and step into the unknown in a new way!
SWEAT LODGE -PURIFICATION CEREMONY This ceremony will take place in the evening and can be used as a way to purify and release what is no longer serving you. This experience will help to prepare you for the Sacred Cacao Ceremony the following day. The cost for the Sweat Lodge is $35.00 and must be paid by November 1st. Payment can be submitted via PayPal.
American Disabilities Act
The Americans with Disabilities Act requires companies or organizations that lease space in public facilities for events, conferences, seminars or meetings to ensure those activities are accessible to people with disabilities.
Please describe any special accommodations or access you may need to participate in the Wild Women or Awakening the Conscious Masculine Immersion.
If you answered "yes" to the above, please provide more information so that we can support you during the Immersion.
Agreement of Release and Waiver of Liability
I acknowledge that I am participating in a Wild Tribe Immersion which is either the Way of the Wild Woman- Fire Woman or Awakening the Conscious Masculine at the Hermosa Beach House in Playa Hermosa/Jaco Costa Rica during which I will receive information and instruction about yoga, holistic practices including shamanic and tantric initiations and other healing modalities. I recognize that yoga requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I also acknowledge that there will be nudity but that I will not be required to partake in any sexual activities with other participants. 2. I represent and warrant that I am physically fit and I have no medical conditions that would prevent my full participation in activities unless discussed prior to the Way of the Wild Woman Immersion with organizer, Veronica Clark. 3. I understand that if I have specific medical conditions, I will list them on my Participant Information form prior to my arrival. 4. In consideration of participation in the Way of the Wild Woman or Awakening the Conscious Masculine Immersion, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the immersion, including any and all activities done with the group, or as an individual at the Way of the Wild Woman or Awakening the Conscious Masculine Immersion. 5. In further consideration of participating in Way of the Wild Woman or Awakening the Conscious Masculine Immersion, I knowingly, voluntarily, and expressly waive any claim I may have against Veronica Clark, Sol Revolution, Inc., and other immersion instructors, for injury or damages that I may sustain as a result of participating in the immersion. I, my heirs and legal representatives forever release, waive, discharge and covenant not to sue Veronica Clark, Sol Revolution, Inc other immersion organizers and/or instructors for any injury. 6. CANCELLATION POLICY: I understand that the registration fee is non-refundable. Should the event be canceled by Hermosa Beach House in Playa Hermosa/Jaco Costa Rica or the Wild Tribe organizer Veronica Clark, all fees will be refunded back to me. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree and confirm the above terms.
Type in First and Last Name to agree
This date indicates the date that you agreed to the above Agreement of Release and Waiver of Liability.
Photo and Video During the Event
If you checked that you have some concerns with photography, please indicate your concern below.
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Thank you, Wild One! See you in Costa Rica!