Name
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
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Email
*
Emergency Contact
*
Emergency Contact Phone
*
(###)
###
####
Date of Birth
MM
DD
YYYY
Occupation
How did you hear about us?
Friend
Shanti Class or Event
Facebook
Instagram
Flyer
Newspaper
Other
Have you practiced yoga before?
What style of yoga have you practiced most frequently?
(check all that apply)
What other spiritual practices or events have you previously attended?
(check all that apply)
What are your goals/expectations during the retreat? What benefits do you seek?
(check all that apply)
How do you rate your current level of physical activity?
How would you rate your level of stress?
On a scale of 1-5, (1 being the lowest and 5 being the highest)
Are you currently taking any medications?
If yes, please list the names and reasons for the medications:
Is there any other information you would like to share?
ACKNOWLEDGMENT
*
By attending this retreat,
A. I affirm that I am solely responsible for my health and well-being, as well as my decision to participate in any program affiliated within this retreat. I agree to inform the retreat facilitators of any activities or movements which I feel could cause injury to myself. I understand that yoga/meditation/breathing techniques are not recommended and are not safe under certain medical conditions.
B. I affirm I do not have any physical conditions or disability that would limit my participation or preclude me from participating in any of the retreats scheduled workshops. Shanti Revolution shall not be held liable for any injury sustained during workshops.. I recognize that yoga requires physical exertion that may be strenuous and may cause physical injury, I am fully aware of the risks and hazards involved. Iunderstand that it is my responsibility to consult with a physician prior to and regarding my participation in this retreat. In consideration of being permitted to participate in yoga and physical classes, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as result of participating in the yoga or physical practices. I also understand that Shani Revolution is not responsible for any expense or liability incurred as a result of my participation in yoga or physical classes, including medical expenses due to any sickness or injury incurred as a result.
C. I agree to listen to my body and monitor myself during every class session.
D. I understand that I am not required to participate in every offering during this retreat.
E. I understand that I am fully responsible for any damage I may have caused to facilities property.
F. I, my heirs or legal representatives' forever release waive, discharge and covenant not to sue
Shanti Revolution, its affiliates or employees for any injury or death caused by their negligence or other acts.
G. I agree to inform the retreat facilitators of any food related allergies. I do not hold Shanti Revolution or any of its staff responsible for any allergies that may develop known or unknown during the time of this retreat.
H. I acknowledge, am aware and agree to Shanti Revolution’s cancellation policy. Cancelation Policy: Event Registration fees are non-refundable due to limited space and availability. However, you are welcome to transfer your ticket to another guest or payment may be applied to a future event. If you do this, you must notify Jodie at 609-384-3813. If event is rescheduled or canceled by Shanti Revolution, event fees will be refunded in original form of payment or can be applied to a future event.
I. I hereby grant Shanti Revolution and its representatives the irrevocable right and permission to photograph, record, and use my likeness, voice, and image in any form, including but not limited to photographs, videos, and audio recordings, for promotional purposes related to the activities of Shanti Revolution including advertising, marketing, social media, websites, newsletters, and other promotional materials.
I understand and agree to the following:
1. Ownership: All rights, including copyright ownership, to the photographs, videos, and recordings shall belong to Shanti Revolution. I acknowledge that I have no rights to the photographs, videos, or recordings, and I Will not receive any compensation f royalties from their use.
2. Consent: I consent to the use of my likeness, voice, and image in any form and for any purpose related to the activities of Shanti Revolution without any prior review or approval.
3. Release and Waiver: I release and discharge Shanti Revolution, its representatives, employees, and affiliates from any claims, liabilities, demands, actions, or causes of action arising out of or related to the use, distribution, or display of the photographs, videos, or recordings, including any claims for defamation, invasion of privacy, or infringement of any personal or proprietary right.
4. Confidentiality: While Shanti Revolution will make reasonable efforts to maintain the privacy and confidentiality of my personal information, I understand that once the photographs, videos, or recordings are in circulation, they may be viewed or accessed by third parties. I waive any claims or damages arising from the unauthorised use, distribution, or alteration of the photographs, videos, or recordings by third parties.
5. Revocation of Consent: I understand that I have the right to revoke this consent at any time by providing written notice to Shanti Revolution. However, I acknowledge that revoking consent will only apply to future uses and will not affect any photographs, videos, or recordings that have already been used or published.
I understand and agree to the terms
I do not agree and would like to cancel
Date
MM
DD
YYYY
Thank you! We can’t wait to see you at the Shanti Revolution Sound Healing Retreat at Amethyst Retreat Center on May 31 - June 2 .
Please plan to arrive sometime between 12pm - 4pm on Friday May 31 to check in and be ready for our first meal together at 5pm
Some items you will want to bring with you - Camping gear ( if you need anything please reach out , we have extra supplies that can be loaned )
Address 44 Buffalo Creek Road
Contact: Jodie (609) 384-3813
Emily (609) 319- 8308
Please reach out with any questions
