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EPIC RETREAT MEMBERSHIP AGREEMENT AND LIABILITY WAIVER

Please read the entire document below and let us know if you have any questions. This link contains information sensitive in nature, confidential, and/or privileged. Please dont copy, disclose, disseminate, or use the contents of this document for any other purpose.

July 18, 2018

Welcome. Space is limited and for the safety of all, we will reserve the right of entrance. If you have any questions or concerns please contact us at any time, before, during or after the retreat. For your safety as well as the others, an absolutely truthful reply to all questions is necessary. Please review the following pages completely. Your answers will be kept confidential.

Your signature is required to be able to participate. Please use your legal name on this form that matches your document. Thank you

Assumption of Full Responsibility for my participation in Epic: A Radical Respect Retreat for Young Men Liability Waiver

I do hereby, formyself, my heirs, executors and administrators, remise, release and forever discharge La Ventana and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any and all claims, demands, actions or causes of action which in any way arise from my participation in the above noted event. I do hereby certify that to the best of my knowledge and belief the particpant is in good health. In case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. I certify that the participant is completely healthy (both physically and emotionally) and capable of participating in these activities. I understand that it is solely my responsibility to determine whether there is any medical or psychological reason that he should not participate in our events or activities.

I Agree

I have read this agreement, and agree to its terms. I release the organizers from any responsibility for mental or physical damage resulting from the minor's participation in the retreat. I am fully responsible for the consequences of the minor participation, before, during and after the retreat.

I Agree

The participant will be in the retreat voluntarily without pressure from anyone. I understand that payment is towards the cost of the organization of the retreat itself.  I agree not to hold responsible for any damages or problems that might occur in any way connected with this retreat - neither the organizers of this retreat nor the owners of the property where this retreat is taking place. 

CONFIDENTIALITY - It is important to maintain the safety of everyone in the program. As such, the participant agrees to keep whatever is said or shared in the sessions, completely confidential. There may be times when personal information or opinions are shared as part of the process. We must respect each other’s privacy and keep personal information confidential. Please do not share anyone's personal stories outside of the program. You can share what you learned and you can share what you personally felt; however, do not share what the other person/people said or shared. E.g: You can say, when a person talked about an experience they had, I felt....

I Agree

RESPECT - We strive to treat everyone with respect, setting up space to allow that each person is heard before others speak a second time, that differences are honored and accommodated when needed. We ask that participants be aware of physical space and respect each persons boundaries, ask before hugging, watch voice tone and sarcasm which can creep in as humor, feelings are welcomed and we take care not to invalidate people or groups of people. Be comfortable and take care of yourself, we want to be flexible and still provide a safe structure of all participants.

I Agree

PLEASE, NO FRAGRANCES WHEN YOU ATTEND ANY GATHERING OR SESSION - Many people are extremely sensitive to chemical fragrances and with everyones cooperation this guideline means more people can participate with comfort and full attention. This includes attendance in classes, workshops, gatherings, or private sessions. Some things to avoid: cologne, perfume, lotions, all scented hair products, shaving lotion, smoke, laundry aids - scented detergents/fabric softeners/dryer sheets. If it smells, dont wear it on your body or your clothes. Only natural scents please

I Agree
 

Participants are prohibited to use any drugs, including marijuana, cigarrettes or pharmaceuticals not cleared by us before, during or after the retreat and explicitly ask you not to use these near our land or the temple space or to offer or to share these with others participating in the retreat.

I Agree

Cancellation Policy

La Ventana reserves the right to cancel any event at any time. Reservations are personal and non transferrable. If La Ventana has not received your signed waiver 1 week before the ceremony, reservation will be cancelled without refund. 

I Agree

Cost of the Weekend Retreat Per Youth is $300.  Early Bird paying in Full before March 11th $250. The cost includes retreat from Friday at 5pm to Sunday at 5pm, meals and participation in all activities and workshops during the event, including materials. **A Non-Refundable Deposit of $150 is due by March 11th. **The Remaining Balance of $150 is due by April 11th. There will be a waiting list, if you arrive at our registration site and the dates do not appear in the list to reserve, we might be full.  We will keep you posted if a space opens. If your tuition balance is not completely paid in full by April 11th, your spot will be given to someone else. 

I Agree

I understand that it is MY RESPONSIBILITY to drop off and pick up this child at the times discussed and agreed upon at La Ventana Retreats. Absolutely no credit or refunds for work conflicts or transportation issues, so please plan ahead! 

I Agree

I understand the cancellation policy and agree with the terms.

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Signature*
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Signature*
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
More about Participant!

Gender

Name of School *

Grade *

Ethnicity *

Where are your parents from? *

Describe yourself in a few words *

What makes you happy? *

What makes you sad? *

What challenges are you currently facing in life? *

What do you wish to explore in this Epic Retreat? *

What would you like to change in your life? *
Health
Does the participant have any physical health problems, medical conditions or diseases?*
No
Yes

If the answer is yes, please tell us the details
Is the participant taking any medications?*
No
Yes

If the answer is yes, please tell us the details

Does the participant have, or ever had, any mental health/emotional/psychological illness(es) or condition(s) such as chronic depression or anxiety, panic attacks, manic depression, schizophrenia, etc.? Please explain the details. *

Has the Participant ever been hospitalized? If so please explain. *

Any known Allergies? If so please explain. *

Any dietary restrictions? If so please give us the details. *

Is there anything else we should know?
Camping Gear
Tent*
Sleeping bag or bedding*
Media Release
La Ventana Retreats has my permission to use my or my child's photography to promote future events. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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