PermaPeru Registration Form
Deadline Reminders:
Registration, $500 Deposit, Passport #: Due May 1st, 2019
Full Payment Balance, Travel Flight Info & Travel Insurance Info: Due June 15th, 2019
Once your application is received, we will set up an introductory phone call prior to finalizing registration.
Email address *
Name *
As it appears on your passport
Your answer
Phone *
Your answer
Address: *
city, state, zip & country
Your answer
Passport #:
Please include expiration date and nationality
Your answer
Birthdate
day/month/year
Your answer
Emergency Contact Info: *
Name, relationship, email, phone
Your answer
How did you hear about us?
Your answer
Special Dietary Requirements: *
Allergies *
Required
Do you have any heart or blood pressure conditions? *
Required
Please describe any other medical issues or physical limitations we should be aware of: *
Your answer
Lodging is included in the cost for all 10 nights in comfortable shared accommodations - double room & suite accommodations based on the locales.
If you prefer a private room or would like to coordinate sleeping/bed arrangements with another registering traveling partner, please indicate (ie. private room: shared/solo; double room: single/double bed & name of traveling partner) :
Any additional costs incurred will be quoted to you prior to confirming your registration
Your answer
Have you completed a Permaculture Design Course (PDC) or previously taken an introductory Permaculture course?:
If so, please describe
Your answer
Please describe any other previous experience in land-based fields:
(ie. gardening, farming, green building, community activism, land arts, permaculture etc.)
Your answer
Please explain your interest in this program or personal goals during your time with us:
Your answer
Special skills, talents, inspirations, passions:
Your answer
Any additional info, questions or concerns you would like to share:
Your answer
I hereby give PermaPeru permission to use my photographic likeness in images taken during this retreat on their website and in print material for the use of promotion of their projects and programs: *
Waiver & Release of Liability & Assumption of Risk
By submitting your application to PermaPeru, you agree to the following terms and conditions. This is a legally binding document. It is important that you read it carefully before submitting your application and check the box below. Submission of your application to PermaPeru implies your agreement to the terms stated herein.
WAIVER & RELEASE OF LIABILITY & ASSUMPTION OF RISK
I HEREBY ASSUME ALL THE RISKS OF PARTICIPATING IN THIS RETREAT, COURSE, SERVICE FOR WHICH I AM REGISTERING BY SIGNING THIS DOCUMENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on part of the persona or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
I am participating in classes, workshops, events and excursions offered by PermaPeru during which I will receive information and instruction. I recognize that it may require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.
I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the classes and excursions. I represent and warrant that I am physically fit and I have no medical conditions that would prevent my full participation. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems, which preclude my participation in this activity or event.
In consideration that this WAIVER & RELEASE OF LIABILITY & ASSUMPTIONS OF RISK FORM will be used by the event holders, sponsors and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said activity or event.
In consideration of being permitted to participate, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating.
In consideration of my registration and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: PermaPeru and/or their directors, officers, employees, volunteers, instructors, representatives, and agents, the activity or event holders, activity or event sponsors, property owners or event volunteers;
B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE TO NOT SUE the entities or persons mentioned above from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by negligence of release or otherwise.
I acknowledge that PermaPeru and their directors, officers, volunteers, instructors, representatives, and agents are NOT responsible for the errors, omissions, acts if failures to act of any party or entity conducting a specific event or activity on behalf of PermaPeru.
I acknowledge that this activity or event may involve a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, elevation, negative reaction from air or waterborne bacteria or viruses, sanitation problems, food poisoning, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, students or for any other cause beyond the control of PermaPeru and/or entities.
My participation in the retreat, course or other activities sponsored, promoted or conducted by PermaPeru is purely voluntary; I voluntarily elect to participate in those activities despite the risks involved.
I hereby consent to receive medial treatment which may deemed advisable in the event of injury, accident, and/or illness during this activity or event.
I further assume full responsibility for any and all expenses and costs caused by or associated with, my illness or injury during the period of, or associated with, my participation in the activities of PermaPeru retreat, course or other activities sponsored, including, but not limited to, medial expenses, hospital bills, medications and emergency transportation. I acknowledge that those expenses are not covered by any contribution for participation in the activities of, or volunteering for, PermaPeru.
The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND BY SUBMITTING BY REGISTRATION AND CLICKING YES ABOVE, I SIGN IT OF MY OWN FREE WILL.
Print Name & Date
Your answer
I have read and accept the terms and conditions above *
Required
A copy of your responses will be emailed to the address you provided.
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