1. VOLUNTARY APPLICATION, ACCURACY OF INFORMATION
I acknowledge that I have voluntarily applied to participate in the Inward Bound Mindfulness Education, Inc (iBme, Inc) retreat for teenagers and/or young adults entitled Virginia Teen Retreat, referred to below as "this event", at the premises of Serenity Ridge Retreat Center hereafter referred to as “facility”, in the city of Shipman, VA. I acknowledge that all information on this application is accurate and complete - including all medical information.
2. ASSUMPTION OF RISK
I am aware that participating in this event may involve strenuous physical activities such as work meditation (washing dishes, cleaning bathrooms, etc.), yoga, or movement classes, as well as risks associated with hiking in a rural setting including contact with poison oak and wildlife. I am also aware that this is an intensive meditation retreat and that participants in such retreats may experience intense and unusual psychological, spiritual, and/or physical states of mind and body arising from the meditation and associated retreat activities. I am voluntarily participating in these activities with full knowledge of the risks involved, and hereby agree to accept any and all risks of harm that may result from these activities.
3. PERMISSION TO TREAT
Consent is hereby given for the applicant to attend an iBme retreat. I hereby give consent for Inward Bound Mindfulness Education, its staff, and its volunteers to provide medical care to me or my child. This may include assisting participants with self-administering over-the-counter medications, offering basic First Aid, or determining if professional care at a hospital is necessary. I understand that for the safety of participants, it is iBme's policy to hold on to any medications that participants bring with them, including over-the-counter medications, and help participants to self-administer these medications when/if necessary. Permission is given for any emergency anesthesia, operation, hospitalization or other treatment (whether for an emergency or not) which might become necessary. I agree to be responsible for any and all costs associated with such treatment. All information will be kept confidential except that information may be disclosed to any medical or other provider as needed for my (or my child’s) care. If iBme arranges for treatment for me (or my child) by a medical provider, I authorize that medical provider to release information about me (or my child), and my (or my child’s) condition and treatment to iBme. I understand that failure to disclose medical information could result in serious harm to me (or my child) and fellow participants. If I (or my child) arrive at the retreat with a preexisting medical, behavioral or psychological condition which is not indicated on my medical form, I understand that this may affect whether iBme allows me to attend the retreat.
As consideration for being permitted by iBme, Inc and the retreat facility to participate in these activities and use their facilities, I hereby agree that I, my parents, my guardians, my assignees, heirs, distributees, and legal representatives will not make a claim against, sue or attach the property of iBme Inc or facility, their affiliates, employees, agents or volunteers or any of their affiliated organizations for injury or damage resulting from acts, howsoever caused, by any employee, agent, or contractor of iBme Inc or facility, or any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, or contractor of iBme Inc and facility, or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed. I hereby release iBme, Inc, facility and any of their affiliated organizations from all actions, claims or demands that I, my parents, my assigns, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this event, except when an employee, agent, or contractor of iBme Inc or facility or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed.
5. KNOWING AND VOLUNTARY EXECUTION
I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract among myself, iBme, Inc, facility and/or their affiliated organizations, and sign it of my own free will.
I do hereby confirm the consent given you with respect to your photographing or recording me or my child in connection with the iBme,
Inc Teen Retreat. I hereby grant to you the right to use all the videos, photographs, and audio recordings which you may make of me or my child, and the right to use my name and/or child’s name or likeness in or in connection with publicly displaying the retreat or any other use of such video, picture, or audio recording.