Level 3 & 4 Registration


Congratulations on having chosen to participant in our Experiential Workshop Levels 3 and 4 (“Integration” and Transformation”). This application must be completed and returned prior to your participation.

Workshop Dates:
“Integration” Level 3 Retreat
July 22, 2020 – July 25, 2020
“Transformation” Level 4 Retreat
July 26, 2020 – August 2, 2020
Reintegration
August 8th

Name:*
Home Address:
Primary Phone #:*
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Alternate Phone #:
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Email Address:*

Emergency Contact (Must be someone NOT attending this retreat)

Contact Name:*
Relation:
Contact Primary Phone #:*
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Contact Alternate Phone #:
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Medical Information

Primary Physician:*
Physician Phone #:*
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Medical Insurance Provider:*
Insurance Phone #:*
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Medical Insurance ID #:*

You MUST provide a copy of your driver's license and medical insurance card with your application. You can upload a scanned version of those below or provide a copy to an Awareness Institute representative. Your application is not complete until we receive this information.

Upload a File:

Health History

Due to the wilderness nature of Level 4, basic health information and disclosure of known medical conditions is requested from each participant to assist in the unlikely event of an emergency. You are required to bring a basic first aid kit and all needed prescription medications for the duration of the retreat, as well as any type of related remedy – i.e. bee sting kit, asthma inhaler, etc. Additionally, extensive first aid kits will be strategically placed on the mountain, and staff will be available in case of an emergency.

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 in #1:
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.
Do you have previous backpacking or wilderness experience? If yes, describe:
Describe your current level of health and fitness.
Do you exercise regularly? If yes, describe what type and how often:

Do you eat/use the following?

Meat:
How often do you eat meat?:
Dairy Products:
How often to you consume dairy?:
White flour products & sugar
how often do you consume white flour and/or sugar?
Alcohol or recreational drugs:
how often do you consume alcohol or use drugs?:
Tobacco:
How often do you use tobacco?:
Additional health related comments or information
To fully benefit from the Level 4 retreat, please share your reasons for attending, and what you intend to accomplish by your participation:

Meetings requiring attendance prior to the retreat:

I acknowledge my responsibility to myself and to the group, and therefore agree to be adequately prepared by attending the following required activities:

  • Gear Demo: Tuesday July 10th 6-9pm (at the Institute)
  • Gear Check: (At the Institute) You will bring your backpack and gear to this event. (select one below)
Select a gear check day:

Please read the following sections carefully and completely. If you have any questions, contact a representative.

I have read and understand that if I have any medical or mental condition that requires medication, I am responsible for having this medication available to me at all times throughout the duration of the Level 4 Wilderness Retreat. Further, I will inform the Awareness Institute (which is operated by Aspire Foundation) staff of any medical condition of which I am aware and which may arise during this retreat. I acknowledge that if I have a health condition for which I am under the care of a medical or mental health practitioner, that I have discussed the nature and duration of the cleanse program and the Level 4 Wilderness Retreat with such practitioner. I certify that I have their approval and consent to participate fully in this Level 4 program. I agree that Level 4 is a co-creation from beginning to end, and I assume full responsibility for my own well-being.

I understand that The Awareness Institute and its representatives neither claim nor imply that the dietary programI am choosing to participate in will cure or treat any disease or mental condition. I further understand that the representatives are not qualified to offer any medical or mental health advice or diagnosis. I agree that if I have medical or mental health concerns, I will seek the counsel of a licensed physician or mental health counselor. I further certify that The Awareness Institute and its representatives have not suggested that I cease any medical or mental health care. I understand that the decisions I make regarding my health care are my responsibility and I certify that I will not hold The Awareness Institute and its representatives responsible for the consequences of my decisions.

I hereby agree to indemnify and hold harmless The Awareness Institute and its representatives and other participants if any lawsuit is brought against them for personal injuries or wrongful death arising from my participation in the Level 4 retreat. I have read and understand the foregoing and agree to the terms and conditions set therein. I have been given the opportunity of consulting with an attorney before I have signed this agreement.

Entering your name in the field below serves as your signature consenting to the information above.

Signature (1):*
Date (1):*

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 and its 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.

Use of non-prescription drugs or alcohol is not permitted during the course of the workshop. If you are dependent or addicted to any non-prescribed drug, or you would experience difficulty from not using it during the retreat, it is recommended that you NOT participate at this time.

Informed Consent

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 and 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 retreat. I agree to be responsible for my own health and safety. 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 and indemnify them from any and all liability arising out of any acts on their part including negligence.

I am aware that my deposit for this workshop is non-refundable, though it may under certain circumstances be transferable to the next scheduled workshop, and I am liable for the full tuition once the workshop has commenced.

Any dispute arising from or relating to this agreement for personal injuries, contractual disputes, wrongful death, or any other reason shall be submitted to a binding arbitration before an arbitrator selected from the American Arbitration Association in arbitration conducted according to the rules of that association.

Entering your name in the field below serves as your signature consenting to the information above.

Signature (2):*
Date (2):*

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.

Entering your name in the field below serves as your signature consenting to the information above.

Signature (3):*
Date (3):*

Photo Release

I grant to Awareness Institute (AI) the right to take photographs of me at all AI events. I authorize Awareness Institute, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Awareness Institute may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Entering your name in the field below serves as your signature consenting to the information above.

Signature (4):*
Date (4):*