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Retreat Waiver
Thanks for showing interest in the Nourish Retreat, please fill in the fields below
Email *
Full Name *
Email *
Address *
Phone number *
Please provide Emergency Contact Details in the following order:
Name, Number and Relationship to
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The food we will be providing will be vegetarian. 
Do you have any food allergies we should be aware of when preparing meals? Peanuts/Gluten/Celery/Eggs/Dairy/Mustard/Sesame/Lupin/Soy
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I understand that holistic therapy practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances or supplements.
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I acknowledge and understand the activities this weekend do not take the place of medical advice or care, if in doubt I am responsible for seeking advice and expert support from my General Practice Doctor or health care provider for any physical and psychological ailments I may have.
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Are you sensitive to any fragrances or perfumes?
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Has your doctor ever made you aware that you have a heart condition and should only do physical activity recommended and verified by a doctor?
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Do you or have you felt pain in your chest while exercising in the past six months?
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Do you lose your balance easily because of dizziness, syncope (fainting)?
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Do you have any bone or joint problems, that could be made worse with physical activity?
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Is your doctor prescribing you drugs to manage any blood pressure, heart conditions or any other condition you would like to make us aware of?
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Are you or have you been pregnant in the last six months?
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Is there any other reason you should not participate in exercise or do you have any other concern about taking part in an exercise program?
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A note on privacy:
No information about any client will be discussed or shared with any third party body. This retreat is focused on client confidentiality and aims to support clients with respect. By signing up to the Nourish Retreat you understand this and permit the teachers knowledge of any medical conditions that will affect your time at the retreat below:
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A copy of your responses will be emailed to .
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