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Rejuvenate with Mindfulness Weekend Retreat
Friday January 25 - Sunday, January 27, 2019 at the Franciscan Renewal Center in Scottsdale, Arizona.
Please fill out this registration to confirm your place.
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Address *
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Phone number (Best number daytime) *
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Emergency Contact name *
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Emergency Contact phone number *
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Age *
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Gender *
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Briefly describe why you are interested in attending this retreat. *
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Do you snore? *
Do you have any dietary restrictions? *
If yes to dietary restrictions, please describe below.
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Do you have any other allergies that we should know about in case of emergency? *
If yes to allergies, please describe below.
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Do you have any major health conditions we should know about? *
If yes to major health condition, please describe below.
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Are you concerned about or being treated for any mental health issues? *
If yes to mental health treatment, please describe below.
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Select accomodation *
If you have a roommate preference please specify here.
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Waiver and Informed Consent
This retreat includes skill training in relaxation and meditation methods as well as gentle stretching (yoga) exercises. It will also include some voluntary verbal exploration of people's experiences of some of the exercises which may cause certain discomforts to arise. During this retreat I will be asked to practice these appropriate to my abilities. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises, I am under no obligation to engage in these techniques. This retreat is designed to help me learn these skills appropriately and to never push beyond my capabilities. I also understand that I am wholly responsible for any physical or mental states or experiences that arise due to participation in this retreat.

This Program is in no way a substitute for medical, psychiatric, psychotherapeutic treatment or healthcare-related treatment of any kind. I also understand that no guarantee is made as to the outcomes or results of this educational retreat.

In consideration of being permitted to participate in this retreat, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, and discharge The Institute for Mindful Works, the Scottsdale Institute for Health & Medicine, Christy Cassisa, Paul Sugar or any other teachers or organizers, and the landlords and The Franciscan Renewal Center from liability from any and all claims including negligence which result in personal injury, accidents or illnesses (including death), and property or financial loss which occurs during, or which arises from participation in this retreat.

I understand that participation in this retreat carries with it certain inherent risks. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I understand that instructors are not acting as clinicians, therapists or psychologists and do not purport to treat any condition or ailment and that I am strongly encouraged to maintain communication with my caregiver(s) about any changes in my condition(s) and before making any changes to medications or activities.

There are some instances in which participation in this retreat may not be appropriate at this time. These include active addiction or recent sobriety within the previous year, suicidal ideation or active psychosis. I certify that have disclosed herein any and all information that might be relevant to determining my suitability to participate in this retreat.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in participation in this retreat. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Informed consent: By e-signing here, I certify that I have read, understand, and agree to the above waiver and consent. *
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Payment Selection *
Refund Policy
We will refund 75% of your registration fee if cancelled on or before January 1, 2019 and 50% if cancelled on or before January 15. After January 15, no refunds will be given for cancellations or no-shows.
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