Retreat Application


Thank you for submitting your registration!

Please take a moment to fill out the application below and tell us a little more about yourself. Please excuse any duplicate questions.

For which workshop are you applying?:
Name:*
Email:*
Address:*
Mobile Phone:*
-
Other Phone:
-
Birth Date (mm/dd/yyyy):*
Birth Time:*
 : 
Is your birth time exact (from your birth certificate) or an estimate?
Birth Place:*
Emergency Contact:*
Emergency Contact Relationship:*
Emergency Contact Phone:*
-
Current Medications?:
Illnesses, injuries or physical limitations?:
If you have been hospitalized or in treatment within the last 12 months, please describe:
Are you in individual or group therapy? Is your therapist aware of your participation in this retreat?
Please take a moment to share what is challenging you in your life right now, and what your intentions are for this retreat. Answering this question does not guarantee you will achieve these results, however being clear in your focus will greatly enhance your experience.
Please read the following section carefully and completely. If you have any questions, please contact an Awareness Institute representative. 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. Any 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, 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 , 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.

*
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.
*