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 November 2019.

Name
Name
Date of Birth
Date of Birth
Which Immersion are you attending? *
Select one of the options below:
Examples might include but are not limited to: meet and connect with other wild women; practice communication skills in difficult situations.
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
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? *
Cancellation Policy
The cancellation policy is located on the registration page. Please be sure to read it.
Agreement of Release and Waiver of Liability
Type your first and last name
Date
Date
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 retreat. By signing below, you are giving The Way of the Wild Woman & 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!