WILD TRIBE IMMERSION REGISTRATION AND AGREEMENT OF RELEASE & WAIVER OF LIABILITY 

BY FILLING OUT THE FORM BELOW, YOU ARE ELECTRONICALLY COMPLETING TO THE AGREEMENT OF RELEASE & WAIVER OF LIABILITY FORM FOR THE WAY OF THE WILD WOMAN: FIRE WOMAN IMMERSION OR THE AWAKENING THE CONSCIOUS MASCULINE IN THE SACRED JUNGLES OF COSTA RICA ON NOV 4 - 9TH, 2018

Name *
Name
Which Immersion are you attending? *
Select one of the options below:
Some aspects of this immersion will include nudity. Are you willing to participate in the activities that involve nudity so long as it relates to the healing nature of the immersion? *
Nudity during the Way of the Wild Woman and Awakening the Conscious Masculine Immersions is used as a form of healing embodiment to help move away from body shame and sexual wounds that may still be present. Nudity is also used as a way to celebrate the feminine and masculine divine present in each of us!
Allergies and Dietary Needs
Other Thoughts
Emergency Contact Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Optional Experiences
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!
Ziplining Experience and Local Lunch Outing *
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.
Sweat Lodge - Purification Ceremony *
Beach front, purification ceremony. This experience will take place in the evening and is approximately 3-4 hours. We will enjoy light, restorative, snacks on the beach afterwards.
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.
Do you have metal plates, epilepsy or are pregnant? *
Agreement of Release and Waiver of Liability
Type in First and Last Name to agree
Type in First and Last Name
Date *
Date
This date indicates the date that you agreed to the above Agreement of Release and Waiver of Liability.
Photo and Video During the Event
During the Way of the Wild Woman and Awakening the Conscious Masculine Immersions, the organizers will often take photos and/or videos of the participants engaging in workshops. Your photos could be used in future publications, multimedia presentations, and on the internet. You will also have access to the photos after the immersion. By signing below, you are giving The Way of the Wild Woman, The Wild Tribe, & Veronica Clark permission to use photos for the purposes stated above. *
We love to stay in contact!
Thank you, Wild One! See you in Costa Rica!