Wild Self Women's Retreat 

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We are excited that you’ll be joining us for this transformational weekend! Thank you for thoroughly filling in the following registration form so we can provide the best possible programming.  Please complete this registration form on a computer, not on your phone.  

 

Fill out the information below, then click Next Page to proceed.



General Information for Arranging Flights and Transportation:

- Check in is on Thursday, October 24 starting at 4 pm at Sylvan Dale Ranch

- Check out is on Sunday, October 27 at 11 am

INVITEE INFORMATION






Page 2

Registration Questions




Getting to Know You






Health Questions

No Barriers USA requires all participants to complete this medical assessment.

Please help us optimize the medical review process by:

1.) Being honest. NBUSA wants you to participate and we strive to accommodate most medical conditions. 
2.) Being thorough. Fill out the medical fields and forms completely. Incomplete or blank answers will require NBUSA to contact you and may delay your acceptance to the program.
3.) Communicating changes. If there are any new medical conditions or changes in medical status or medications before your program starts, let us know by emailing julie.fast@nobarriersusa.org or calling 970-484-3633. 

General information

Medical History:

Yes No

Yes No



Medications: Please bring AN EXTRA supply of any prescription medications that you will need to take. If you have had an anaphylaxis reaction please provide your own epi-pen. 

Yes No



Altitude Sickness: When traveling above 8,000 feet, do you have a history of:
Yes No Unsure
Sickle Cell: Have you or anyone in your immediate family tested positive for:
Yes No Unsure

Page 5

Insurance Information






I hereby ascertain that I am in sound physical, emotional and mental health to participate in the retreat.



Adult Risk and Release Agreement


Payment

Retreat cost: $875
Price includes: Lodging, meals, snacks, activities, swag bags and inspiration. 
Payment Information






Billing Address