Registration Form & Liability Waiver
AcroRocks New Years Retreat: December 27th to January 1st
Email Address: *
Name: Last, First *
Cell Phone # *
Emergency Contact Name and Phone #: *
Please list any allergies including insect bites, bee stings, foods, medications etc *
Do you have any dietary restrictions: *
Climbing Harness Size:
MARK ONLY IF YOU NEED A HARNESS *Pant waist size. please mark M for male and F for female
Climbing Shoe Size
MARK ONLY IF YOU NEED *Please mark M for male and F for female. If you have never worn climbing shoes before or unsure, please put down your street shoe size and specify Street Shoe Size.
What is your perceived Climbing Level? *
Tell us a bit about your climbing background. *
if you don't have one that is fine just tell us
What is your perceived AcroYoga Level? *
Tell us a bit about your AcroYoga background. *
again if you don't have one its all good
How did you find out about AcroRocks *
if someone referred you please list their name
Do you have any specific skills you would like to cover while at the retreat? *
Travel Plans: Where are you coming from? *
Travel Plans: Will you be driving and if so, how many people can fit in your car for carpool? *
Travel Plans: If no above, do you need a ride? Where from? *
Gear Rental Information
**There is an additional charge for gear rental. Check if you need to rent one or more.
whats your favorite thing and least favorite thing that happened in your life last year? *
How are you Paying? please make sure there are no fees as we need to receive the full payment *
RETREATER CONSENT AGREEMENT:                 *
I agree that I am participating in a Yoga Squirrel Event, during which I will receive information and instruction about rock climbing, yoga, and AcroYoga.  I recognize that both rock climbing and AcroYoga require physical exertion that may be strenuous and may cause physical injury; I am fully aware of and accept full personal responsibility for 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 rock climbing and yoga retreat.  I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the rock climbing and yoga retreat.  In consideration of being permitted to participate in this climbing and yoga retreat, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, past present or future, which I might incur as a result of participating in any climbing, hiking, yoga/AcroYoga practice, workshops and activities at the retreat.  In further consideration of being permitted to participate in this climbing and yoga retreat, I knowingly, voluntarily and expressly waive any claim I may have against YS, Casey Stroud, Sonia Peltzer and any of the YS staff, for any injury or death caused by their negligence or other acts.  I have read the above release and waiver of liability and all terms and conditions and fully understand its contents.  By checking the box below, I voluntarily agree to the terms and conditions stated above.
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