Name
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First Name
Last Name
What is your birthdate?
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MM
DD
YYYY
Phone
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(###)
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Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone
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(###)
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Emergency Contact Email
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What does the landscape of your life look like currently?
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Why do you feel called to participate in this retreat?
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This retreat will be an intimate container and feature bodywork, are you comfortable receiving therapeutic touch from practitioners and other attendees?
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You are sovereign and may absolutely decide in the moment what feels right for you.
We will be encouraging all who feel comfortable being witnessed in full or partial nudity to join and follow along in certain ceremonial spaces as we honor and give love to our own bodies. You will decide what's best for you. Do you have any questions or concerns about this segment of our retreat?
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What are you most looking forward to during the retreat?
*This may be anonymously shared for promotional purposes leading up to retreat!*
Do you currently have routine devotional practices? Have you journeyed into embodiment? Do you consider yourself to be engaging in your "inner work" on a somatic, psychological, or spiritual level?
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All experience is fully welcomed and honored in this space.
Do you have any dietary needs we need to be aware of?
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We will be serving organic, locally sourced meals that contain meat if desired. We stay away from foods that contain gluten, dairy, and soy. As everyone has vastly diverse dietary needs and we will do our best to accommodate, please tell us about yours.
What is your desired lodging situation?
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Shared community room
Double occupancy room
Double occupancy cabin
Single occupancy room
Single occupancy cabin
If you are applying with a friend or relative, please include their name here & your relation:
If you are applying for scholarship, please tell us a bit about the circumstances that have contributed to your eligibility and desire to apply for this position.
Is there anything else you'd like to share with us as we review your application?
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We will reach out to you within 3 days at most to review your application and have a conversation about payment options, and other details. Payment plans will be available.
DISCLAIMER
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We respect all clients regardless of their age, gender, race, national origin, sexual orientation, religion, socioeconomic status, body type, political affiliation, state of health or personal habits. You must be 18 years of age to attend this immersion or accompanied by a guardian if you are under 18 years of age. All participants will be treated with respect and dignity. Privacy and confidentiality are maintained at all times. Please let the facilitators know if you have any contagious condition or any health concern that necessitates modifying or declining your session. The bodywork sessions to be administered are for the purpose of stress reduction, relief of muscular tension, increasing circulation, and promoting a feeling of general relaxation. The bodywork or assessment or herbal care done by Tori Poloski (EMBODYWORK), Cierra Dunn (Inner Rhythms Body Wisdom), or Gabrielle Sisson (The Whole Hearted Witch) does not diagnose illness, disease, physical or mental disorders, nor does the therapist(s) prescribe medical treatment or pharmaceuticals, nor do they perform spinal adjustments or in anyway attempt to perform the functions of a medical doctor. Clients must agree to accurately inform the therapist of the status of their health, and agree to keep them updated on their current level of health and well-being. There shall be no liability upon and to hold harmless Tori Poloski (EMBODYWORK), Cierra Dunn, or Gabrielle Sission (The Whole Hearted Witch) and their relatives, successors, and heirs for any condition which may result from receiving therapeutic massage or bodywork in this space, or from leaving, arriving, and occupying the building and its surrounding premises. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by my mere presence within this interaction or establishment and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others at this event. I hereby release the facilitators and business from any and all claims arising from or in connection with any direct COVID-19 impact during the services and exchange.
I know that I am sovereign in this space to determine what is true and feels good for me.