"Becoming Light' Grand Tetons Participant Survey

Name *

First

Last

Email *

Mailing Address *

City, State, Zip *

Cell Phone Number You Can Be Reached At in Wyoming *

Emergency Contact *

First

Last

Emergency Contact Cell Phone or Best Way to Reach Them *

Relationship to You *

TRAVEL INFO - DATE OF ARRIVAL TO WYOMING *

ARRIVAL AIRLINE *

ARRIVAL FLIGHT NUMBER *

ARRIVAL TIME *

Will you be renting your own car while in Wyoming? *

YES
NO

DEPARTURE INFO: DATE OF DEPARTURE FROM WYOMING *

DEPARTURE AIRLINE *

DEPARTURE FLIGHT NUMBER

DEPARTURE TIME *

Do you have a Roommate preference, or are you willing to share with any retreat participant? *

YES, I have a roommate pre-selected
NO
Willing To Share With Anyone

If you have a roommate preference, please tell us who you plan to room with?

First

Last

*** Are you interested in joining us for a Day Trip to Yellowstone on Sunday, October 9th for an additional fee of $380? *

YES, I am interested
NO, I am not interested
I am interested but need to know more about it

HEALTH CHECK: Do you have any health limitations or physical injuries that will prevent you from participating in excursions or outings? *

Yes
No

If yes, please indicate what health issues or physical limitation you have (e.g., high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)

Do you plan on getting, or have you already recieved the COVID 19 vaccination series + Booster? *

Yes, I am fully vaccinated
No, I am not planning on it at this time
I am not currently, but I plan to be vaccinated before I travel
I am not currently, but I plan to receive a booster shot before I travel

LIABILITY WAIVER #1: As I participate in activities offered by the hosts and special guests, I understand that the offerings of this retreat are not a substitute for medical attention, examination, diagnosis, or treatment. I will receive spiritually related information and instruction, and recognize that my entire participation is voluntary. If any of the activities require physical exertion that may be strenuous and may cause physical injury, I am fully aware of the risks and hazards. Please indicate your acceptance by clicking YES *

Yes, I understand and take full responsibility for my well being

LIABILITY WAIVER #2: I recognize that this retreat requires physical exertion that may be strenuous and may cause physical injury and I am fully aware of the risks and hazards. If at any time during the activities I feel discomfort or pain, I will inform and seek assistance from Wendy and/or Connie. I take full responsibility to rest at any time during the retreat if I feel the need. I will listen to my body and respect its limits on any given day. Please indicate your acceptance by clicking YES *

Yes, I understand and take full responsibility for my well being

LIABILITY WAIVER #3: I understand that all deposits and fees I have paid to-date are NON REFUNDABLE (75 days prior to retreat date) and we are unable refund reservations that have been made on your behalf. Balances will be due in full prior to retreat date of October 3, 2022. I agree that all cancellations made less than 60 Days in advance of the retreat be paid in full and that if I am unable to attend, I may transfer my spot to another person. Please indicate your acceptance by clicking YES *

Yes, I understand

LIABILITY WAIVERS ACCEPTANCE: I have read all of the above releases and waivers of liability and fully understand it’s contents as well as the Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above. *

Yes, I understand

BY ACKNOWLEDGING WITH MY TYPE WRITTEN NAME BELOW, I AM DELIVERING AN "ELECTRONIC SIGNATURE" THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Do you have any other comments, or anything you would like us to know?

“Becoming Light’ Grand Tetons Participant Survey

Please complete the ‘BECOMING LIGHT’ Participant Questionnaire no later than August 10, 2022.