Emergency Contact & Food Allergies Form

Emergency Contacts (sent with payment instructions)

Your Situation 🍍

Gender

Female

Male

Birth Date

Are you taking any medication?

Do you have any food allergies?

Emergency Contact Details

Please fill the following information for your emergency contact…

First Name

Last Name

Relationship

Phone/Mobile

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Your Details

Please make sure your details are the same as you’ve registered with us and submit the form. Thanks!

First Name

Last Name

Agreement of Release and Waiver of Liability:

I hereby agree to take full responsibility for any risks, injuries or damages, which I might incur as a result of participating in the retreat.

Check this box if you DO NOT want us to use your image on our website, social media or other marketing/promotional material.

Where did you hear about us?

Please feel free to fill the space below to introduce yourself, motivation, etc…