Workshop Registration Form Your privacy is important to us. We never sell or share your information with other organizations. The form below gathers information we need to support you in having the best possible experience at the retreat. For which workshop are you registering * Level 1: Initiation Weekend Workshop (June 21-23) Level 2: Inspiration Weekend Workshop (July 12-14) Name * First Name Last Name Referred by If attending with someone please provide name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Gender (select all that apply) * Man Woman Transgender Non-binary Other Special Dietary Requirements: Accessibility needs, Illnesses, injuries, health concerns, or physical limitations we should know about to support your experience Sleep Issues? Current Medications List medications you will require during the retreat including condition, dosage and frequency Are you in individual or group therapy? Is your therapist aware of your participation in this retreat? If you have been hospitalized or in treatment within the last 12 months please describe: Are you a regular cannabis user? * Yes No If yes, please provide frequency/number of times used per week: BIRTH INFORMATION If you have previously provided your accurate birth information to the Awareness Institute, feel free to skip this section. Birth Date MM DD YYYY Birth Time Is your birth time exact (from your birth certificate) or an estimate? Exact Estimate City and State / Province / Region of Birth WORKSHOP INTENTION Answering these questions does not guarantee you will achieve these results, however being clear in your focus will greatly enhance your experience. Describe both your experience of yourself and of life at this juncture in your life, and why you want to participate in this retreat? * What is the one thing you would most like to learn or experience during this retreat? * EMERGENCY CONTACT INFORMATION Emergency Contact * First Name Last Name Emergency Contact Relationship * Emergency Contact Phone * (###) ### #### TERMS AND CONDITIONS Please read the following section carefully and completely. If you have any questions, please contact an Awareness Institute representative. SUBSTANCE USE AGREEMENT * Any use of non-prescription/recreational drugs or alcohol is not permitted during the course of the workshop. If you are dependent or addicted to any non-prescribed drug, it is recommended that you NOT participate at this time. I agree CONFIDENTIALITY AGREEMENT * I agree to respect the confidentiality of all participants and their remarks and actions. I agree to keep all such information private and confidential. The specific content and flow of the processes in the retreat are a unique part of the workshop experience. I agree to maintain confidentiality about the specific processes of the retreat to preserve their spontaneous nature for future participants. I agree PAYMENT POLICY * By clicking here you acknowledge that you are making a binding commitment to a space at the retreat and that you understand payment in full will be required upon acceptance. Your spot in the retreat is not guaranteed until payment has been received. Payments are non-refundable, though may under certain circumstances be transferable to the next scheduled retreat or workshop, minus an administrative fee of at least 10%. I agree ASSUMPTION OF RISK AND INFORMED CONSENT * This experiential retreat is designed to take participants out of their everyday routine so that they can experience themselves in a new way. You are informed; therefore, that participation will require long hours each day and, at times, intense focus and personal introspection. Most components of everyday life will not likely occur on a "normal" timeline. Fundamental issues regarding social conditioning and self-limiting beliefs will be addressed. In the course of such an inquiry, some people will, from time to time, experience a wide range of emotions. As such, the retreat may at times be physically, mentally, or emotionally challenging to some participants. If you are unready or unwilling to experience a full range of physical, mental, and emotional sensations, we recommend that you NOT participate at this time. This retreat may be an adjunct to, but not a substitute for, psychotherapy or for a drug or alcohol treatment program. We advise you that the Awareness Institute facilitators and assistants, although trained in various process techniques, are not licensed mental health professionals; that no licensed mental health professionals will be supervising the workshop. THIS INFORMED CONSENT IS INTENDED TO HAVE LEGAL SIGNIFICANCE. I have read and understand the above Notice, and have truthfully answered the questions on the application form. I willingly, knowingly, and voluntarily assume all risk of physical injury and emotional upset which may occur during or after the retreat, and I hereby agree to hold the Awareness Institute, its officers, directors, employees and agents, harmless from any and all liability. I understand that the Awareness Institute and its staff make every effort to ensure my safety and security throughout the workshop. I agree to be responsible for my own health and safety. I agree PRIVACY POLICY * When you submit this application, your contact information will be added to our secure database and newsletter list. You can unsubscribe at any time. Your information stays with the Awareness Institute program facilitators and is never shared with or sold to other organizations. We may share names and contact information with you and other participants in this program to support in carpooling, connecting, or staying involved with our community after the workshop. I agree Thank you for submitting your Workshop Registration Form. We will be in contact regarding the workshop soon. If you have any questions in the meantime, please reach out to info@awarenessinstitute.org.