Adult Backpacking Retreat

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Participant Information






















More About You






Health Form

General Information










Therapist




Each participant is responsible for any medical expenses incurred and must have their own medical insurance.
Insurance Company



Confidential Medical Record





Drugs/alcohol
We require that you have at least 3 months of sobriety before the start of the retreat in order to attend.
We have a zero tolerance policy for the use of illegal drugs and alcohol during the retreat.

Please list all medications in the fields below. Please list one medication per row, including the Route, Strength, Dose, and Time(s) to be taken. To add an additional medication, please select the checkbox below the previous row.










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Although this retreat is not focused on pushing our physical limits, participants should be fit enough to hike 3-5 miles daily over varied terrain while carrying a 35-40lb. pack. We recommend starting a conditioning regimen if you don’t already have one in place.
















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We cannot accommodate smoking of any kind on this retreat, as there is a high fire hazard in the wilderness areas we are visiting.
























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Liability Waiver

Please read this waiver and sign at the bottom.

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 adults entitled California Wilderness Retreat for Adults, referred to below as "this event" or “program”, in Henry W. Coe State Park.

2. ACKNOWLEDGMENT AND ASSUMPTION OF RISK

I understand that participant share the responsibility for participant’s safety, for managing the risks, and for determining the participant’s suitability for the program in which he/she will participate. I have accurately completed any required iBme application and medical forms and have reviewed all iBme program information provided to me. I have no mental or physical problems or limitations that might affect my ability to participate that have not been disclosed to iBme in writing. I have had the opportunity to ask questions about the program activities and the risks of the program in which I will participate.

I understand and acknowledge that this event has risks and may be physically strenuous. It is impossible to anticipate every activity in which I will engage. The list below includes many of those activities. The activities may include physical activities such as hiking, backpacking, camping, cooking over stoves or open fires, water activities, swimming, river crossings, vehicle travel, rescue scenarios, work meditation, yoga, movement classes, as well as risks associated with hiking in the wilderness setting including contact with poison oak and wildlife. I understand that I may engage in other activities not listed above. The program plan may be modified for any number or reasons, including convenience, weather, emergencies, or unexpected conditions. Activities may be supervised or unsupervised. In particular, participants may have time alone in remote areas.

It is impossible to know or list every risk associated with every activity. Some, but not all, of the risks I may encounter include: unpredictable or harsh weather; earthquakes; lightning; exposure to extreme temperatures (high heat or extreme cold); exposure to high altitude, avalanches and rock fall; rapidly moving water; drowning; wild animals; disease carrying or poisonous plants, insects, animals; improper or malfunctioning equipment; slipping, falling or being struck by objects or persons; risks caused or complicated by any mental, physical, or emotional conditions any participant may have; being separated from other participants and leaders for considerable periods; physical contact with other participants or other individuals; and other natural or man-made hazards. Another risk is the potential misjudgment by iBme instructors, volunteers, other staff members, co-participants or contractors related to my participation, including but not limited to decisions regarding my physical condition and capabilities, weather, water, terrain, route or medical treatment.

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.

4. RELEASE

As consideration for being permitted by iBme, Inc, or one of their affiliates - hereafter referred to as “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, 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 any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, or contractor of iBme Inc, 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 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 any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed.

Additionally, The National Park Service and certain Forest Services may not allow for the assumption of risks other than the inherent risks or for the release of liability for claims of negligence. Therefore, for activities that occur on lands controlled by these agencies where and to the extent that such a prohibition is in writing for that particular location, program or permit at the time of the incident and found by a court of proper jurisdiction to be enforceable as a matter of law, the assumption of risk is limited to assuming the inherent risks and the release of liability is inapplicable. The assumption of all risks, and the release of liability shall remain in full force and effect for all activities or any portion of activities which do not transpire on lands controlled by these federal provisions.

5. ADDITIONAL PROVISIONS

I agree that the substantive law of California (but not any law that would apply the laws of another jurisdiction) governs this document and any dispute or suit I have with the Released Parties. Any mediation, suit, or other proceeding must be filed or entered into only in California.

The assumption of risk, release, and all other provisions in this document are intended to be interpreted and enforced to the fullest extent allowed by law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions, which shall continue in full force and effect.

iBme reserves the right to remove any participant from the program when staff or an instructor believes, in his/her sole discretion, the participant presents a safety concern or medical risk, is disruptive, or acts in any manner detrimental to the program. If I am dismissed or depart for any reason, I will be responsible for all costs of early departure whether for medical reasons, dismissal, personal emergencies, or otherwise.

6. VIDEO/AUDIO

I do hereby confirm the consent given you with respect to your photographing or recording me in connection with the IBME, Inc Wilderness Retreat. I hereby grant to you, your successor, assigns and licensees the perpetual right to use, as you may desire, all the motion pictures, photographs, and audio recordings which you may make of me, and the right to use my name or likeness in or in connection with publicly displaying the retreat or any other use of such video, picture, or audio recording.

7. 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 and/or their affiliated organizations, and sign it of my own free will.




Payment Details

The tuition for this retreat is: $1,995


Required Deposit: $500

Please pay the deposit or the full retreat tuition below

Please select your payment method and pay the deposit amount or full retreat tuition. Online payments will be securely processed through our Authorize.net payment gateway.





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Would you like to include a scholarship gift to iBme with your payment?

Making a gift to iBme helps us maintain our generous scholarship aid: 
we have never turned a teen away for lack of funds.

iBme, Inc. is a tax-exempt 501(c)(3) charitable organization. Your contribution is tax-deductible to the extent allowed by law.




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Please make check payable to iBme, Inc. and send to: iBme, PO Box 516, Concord, MA 01742
Total Current Payment: $

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