Level 3 / Level 4 Registration Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone * (###) ### #### Alternate Phone (###) ### #### Email * EMERGENCY CONTACT INFORMATION Emergency Contact * First Name Last Name Emergency Contact Relationship * Emergency Contact Primary Phone * (###) ### #### Emergency Contact Alternate Phone (###) ### #### HEALTH INFORMATION Primary Physician * Physician Phone * (###) ### #### Medical Insurance Provider * Insurance Phone * (###) ### #### Medical Insurance ID # * List any current or historical medical conditions, including illnesses, injuries or physical limitations. Include any infections within the last year and/or antibiotic treatments, history of heat stroke or sun poisoning, hyperventilation, altitude sickness, bleeding anomalies, high blood pressure, diabetes, cardiopulmonary challenges, asthma, chest pain, head injuries, poisoning, shock, unconsciousness, mental conditions, etc. * Please list any medications and dosages for conditions listed above: * Have you been hospitalized or in treatment for any reason in the past year? If yes, give the reason and dates. * List any accidents or injuries within the last year, and the current condition as a result of that accident or injury: * List any known allergies (Food, medication, bee or insect bites, etc.): * Have you ever done any type of health cleanse, detoxification program, or fasting in the past? If yes, describe what it included, supplements, length of time, etc. * Describe your current level of health and fitness: * Do you exercise regularly? If yes, describe what type and how often: * Do you eat meat? If yes, how often do you eat meat? * Do you consume dairy products? If yes, how often do you consume dairy? * Do you consume white flour and/or sugar? If yes, how often do you consume white flour and/or sugar? * Do you consume tobacco? If yes, how often do you use tobacco? * Do you consume marijuana? If yes, how often do you use marijuana? * Additional health related comments or information: SUMMER SERIES INTENTION Answering these questions does not guarantee you will achieve these results, however being clear in your focus will greatly enhance your experience. To fully benefit from the Level 3 and 4 retreat, please share your reasons for attending, and what you intend to accomplish by your participation: * 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. 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. 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" time line. 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. 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. Agree Thank you! Your application has been submitted. FINAL STEP: Provide a copy of the front and back of your insurance card and driver’s license. Please email your documents to Colleen (preferably in a single PDF document): saccmh@gmail.com
