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Retreat Booking

Welcome to the Sherpa of Souls Retreat Booking Process! We have created what we hope is a seamless process for you to fill out required information that will help us provide a safe and optimal retreat experience. 

 

We have received your 50% deposit which ensures that your spot on the Retreat is secured. This next part of the registration process is critical to help us provide a safe and optimal retreat experience. To that end, please read through all questions carefully and be sure to fill out each entry on both the Medical and Personal Information forms. Please remember to click the “submit” button for BOTH forms, so that we receive both the medical section as well as the personal information section. 

 

Once submitted, SOS staff will review your submission and you might receive a call from a SOS staffer to confirm our understanding, if we have any questions. Once your registration is completed, we will send you a welcome packet with additional information on gear, itinerary, codes of conduct, and more, so you feel confident in preparing for the retreat! Thank you so much for your interest, and we very much look forward to getting better acquainted!

 

- Sherpa of Souls Team

Medical Form Introduction

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All participants are required to complete this form. This form does not require a physician’s exam or doctor’s signature. This information helps to inform us of your physical, emotional and motivational ability to attend our retreat, and to determine if it will be appropriate for you at this time. Please answer all of the questions and provide as much detail as you can. We recommend keeping a copy of this form for your personal records. You must notify Sherpa Of Souls should any medical, psychological, behavioral or legal situations occur after the application has been submitted and the review process has started.

 

Diversity and Non-Discrimination Statement 

Sherpa of Souls prohibits discrimination against any retreat participant or applicant because of race, color, religion, sex, gender, ethnic or national origin, sexual orientation, qualified individuals with disabilities on the basis of disability, or any other category which may be protected by applicable state or federal law. Sherpa Of Souls also promotes respect for all people and will not tolerate harassment based on any of these characteristics nor on differences based on gender identity or expression.

 

Health Insurance 

During our program, you should be covered by your own, your spouse’s, or your family's health and/or accident insurance. Please provide your policy number, company name and address as well as the policy holder’s name. Also required is a copy of the front and back of your health insurance card. Bills for medical treatment will be the responsibility of your insurance company. If you are not covered by health and/or accident insurance, you or your family are responsible for these costs. If you do not have health insurance, we suggest you consider purchasing a short-term health insurance plan.

 

Questions

You can reach Sherpa Of Souls regarding any questions or concerns by calling us at: (401)-935-1593  or by emailing us at peter.alternative@sherpaofsouls.com

Medical Form

Personal info

Emergency Contacts

1:

2:

Ethnicity

Choose an ethnicity (Optional)

Signature Required

Consent is hereby given for the applicant to attend the Sherpa Of Souls retreat and 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, including the costs of evacuation, if any. All information will be kept confidential except that information may be disclosed to any medical or other provider as needed for my care. If Sherpa of Souls arranges for treatment for me by a medical provider, I authorize that medical provider to release information about me, and my condition and treatment to Sherpa of Souls. We must be aware of these conditions. Failure to disclose such information could result in serious harm to you and fellow students. I understand that I may be in remote areas, several hours from any medical facility or where communication, transportation, or evacuation is subject to delay. If you arrive at the program start with a preexisting medical, behavioral or psychological condition which is not indicated on your medical form and you are subsequently unable to participate fully or are forced to leave the program because of that condition, you may be charged an evacuation fee and may not receive a refund of cost.

Medical History: Past and Present

Medical Conditions

Do any of the following condition symptoms apply to you? If YES check next to the item. Provide detail in the spaces below, including the following:  1. Specific symptoms that occur 2. How long does it last  3. Date of last occurrence   4. How often does it occur 5. How you care for it 6. Any restrictions.

Allergies (Medicines, food, environment, etc.)

Current Medications

This includes prescription, over-the-counter, inhalers, herbal supplements, etc.) If psychiatric medication, please list any medications taken or changed within the past 3 months. Please list one medication per box. *NOTE* You must bring any prescription medications in their original bottles with dosage directions. Any changes to above medications or dosages prior to course must be shared with SOS as soon as possible.

Hospitalizations/Emergencies

(Please list any hospital, psychiatric, or urgent care visits within the past year).

Blood Pressure

(Must be taken within 1 year of retreat, and may be taken with apparatus at a local grocery/drug store).

Immunizations

We recommend that all of our participants have a current tetanus immunization (within 10 years).

Psychiatric & Mental Health History

Psychiatric & Mental Health Conditions

Within the past year, do any of the following apply to you? 

If YES, check the box next to the item and provide details on the space below.

Check all that apply

Have you received treatment or therapy for any of the above, either currently or in the past year? If YES. check the box next to the item and provide detail on the space below.

Check all that apply

If you checked any of the above, please provide the following information for your therapist and/or prescribing physician.

Lifestyle

Lifestyle

Do any of the following apply to you? If YES, check the box next to the item and provide details. Include dates, amounts, reasons, etc.

Signature Required

BEFORE you sign, please confirm that you have responded to all general information, past & present medical history, psychiatric & mental health history, and lifestyle questions. Double check the general information form to confirm that you recorded date of birth (DOB), height and weight. This is REQUIRED information.

Early Departure Policy & Commitment Agreement

Sherpa Of Souls asks that each participant come with a willingness to open themselves to the journey that our program aims to begin. All of our staff members rely on the establishment of some basic rules designed to maintain physical and emotional safety. These rules are non-negotiable, reasonable and basic. We will expect the following from participants:

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  • Be open to forming relationships with new people                       

  • Try your hardest and participate to your fullest

  • Make mistakes and learn from them               

  • Follow all physical and emotional safety guidelines 

  • No derogatory language, drugs, alcohol, tobacco or physical violence

 

Our intent is to support guests so they can optimize their experience and fully complete the retreat. However, there are circumstances in which we may require you to leave. Early departures can be due to medical issues, inappropriate use of prescription or non-prescription medications, use of tobacco or tobacco products, use of alcohol, physical violence or derogatory language. A participant will be asked to leave or be removed by staff members if they exhibit behavior deemed inappropriate to our program’s mission and policy. In addition, if we determine that any relevant information was misrepresented or not disclosed in these forms, we have the right to remove the participant from the program for safety reasons.

 

Tobacco, Alcohol, Illegal Drugs and Behavior Policy

Retreat participants cannot possess or use tobacco, alcohol, illegal drugs and/or medications not listed on their medical forms. Participants must also exhibit appropriate behavior and a high level of commitment. Refer to the Early Departure Policy and Commitment Agreement. If a participant fails to uphold these expectations, we may ask them to depart early. This policy is in effect from course start to course end.

 

Disclosure & Policy Agreement 

The information provided on these forms, all other forms and questionnaires is a complete and accurate representation of my physical and psychological condition and history. Should a participant leave the retreat for any reason, there is no refund. I have read the above and, without undue influences from others, agree to abide by the rules and standards of Sherpa Of Souls.

Sherpa Of Soul’s responsibility for a departing individual officially ends at the salutation of the individual; therefore, if the individual refuses to leave in a safe manor after being asked, Sherpa Of Souls will no longer be responsible for their safety, as they are no longer a participant of Sherpa Of Souls.

 

Due to the unique nature and cost of the time/efforts provided by this program and it’s guides, Sherpa Of Souls may require financial compensation if a policy violation occurs during the course, if a significant amount of time is waisted (more than 1 full day), or if borrowed gear or another guest’s gear is damaged. Our staff will be able to explain in detail the circumstances that have led us to seek compensation.

Thank you! Please fill out the next form below.

Personal Information Form

Health Insurance Information

The following information is needed for our insurance records. Each participant is responsible for any and all medical expenses and should be covered by his/her own sickness and accident insurance. If you don't have insurance, or an entry doesn't apply to you, please put "N/A".

Current Physical Activity

List your current physical activity (if any). You will be expected to engage in some rigorous physical activity during this retreat. It is vital that you start (or continue) a physical fitness routine in preparation.

Rate intensity of this activity
Rate intensity of this activity
Rate intensity of this activity

General Questionnaire

Pre-Retreat Evaluation

This survey, along with the same survey that you will take at the end of the retreat, will help us gauge the effectiveness of our programming in assisting participants in personal growth and greater mindfulness. This should take no more than 10 minutes of your time, but please answer the questions thoughtfully and truthfully.

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The Mindful Attention Awareness Scale (MAAS)

 

The trait MAAS is a 15-item scale designed to assess a core characteristic of mindfulness, namely, a receptive state of mind in which attention, informed by a sensitive awareness of what is occurring in the present, simply observes what is taking place.

 

Instructions: Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be. Please treat each item separately from every other item. 

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(Scoring: To score the scale, simply compute a mean (average) of the 15 items.)

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1 - Almost Always

2 - Very Frequently

3 - Somewhat Frequently

4 - Somewhat Infrequently

5 - Very Infrequently

6 - Almost Never

Legal Forms

Please read the privacy policy, and cancellation agreement below in order to complete the sign up. Remember to e-sign the agreement at the end of this form, as you will not be able to take part in the retreat unless doing so, we appreciate your understanding! To download the forms, click on the PDF buttons below. 

Signature Required

I declare that the information that I've provided is accurate. I also agree to the terms and conditions of the legal documents shown above

Thank you! We will be in touch.

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