EmC I RETREAT REGISTRATION Name / Pronouns * First Name Last Name Email * Birthdate * MM DD YYYY Phone * (###) ### #### Emergency Contact * First Name Last Name Phone * (###) ### #### If you are sharing a room with a friend, please list them below. If you are being placed with a roommate, do you snore? Yes No Please list any medications or supplements you take with any regularity. * ALLERGIES * The cuisine at the Retreat Centers are thoughtfully prepared by the staff and onsite chef. They can accommodate gluten free, dairy free and vegan diets if necessary. Other serious medical allergies such as nuts, soy or legumes should be communicated with us. Celiac Gluten Free Dairy Free Tree Nuts Vegan Peanuts Eggs No known allergies If we did not cover a MEDICAL food allergy or other allergy above please explain below. GENERAL CONSENT * I understand that this is a substance-free retreat. I understand that it is my responsibility to get travel insurance. I understand that cancellation of my retreat will result in the TOTAL LOSS of my $1,500 deposit. I understand that the deposit is non-refundable and non-transferrable. I have read and agree to the terms of the cancellation policy. Date MM DD YYYY Thank you for registering for your EmC Retreat. We look forward to connecting with you.
