Name *
Name
Email Address *
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 Name *
Emergency Contact Name
Relationship between you and the Emergency Contact *
Emergency Contact Phone Number *
Emergency Contact Phone Number
Emergency Contact Email Address *
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.
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
Date *
Date
This date indicates the date that you agreed to the above Agreement of Release and Waiver of Liability.
If you checked that you have some concerns with photography, please indicate your concern below.
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