for all programs and services
Registration Form for The Center of Light Programs Please print out or copy and paste into a word document,
fill
out and mail, scan, or fax with payment or credit/debit information. Do not email secure credit card information:The Center of Light, PO Box 389, Ascutney, VT 05030 USA, Phone: 802.674.9585; Fax: 802.674.9586; E-mail: info@sunreed.com If you have not finalized payment, please complete that portion also. All information is kept strictly confidential and shared with no one, except where necessary, and applicable, for our program co-hosts, tour guides, or any authorities required by law. Name ...................................................................................................................................... Gender ............................ Address .................................................................................................................. Birth Date ........................................ City ........................................... State/Province .................... Zip or Postal Code ..................... Country ....................................... Telephone/Fax …………………………………………………............... Cell phone .......................................…………………………………... E-mail Address .........…………………………………………...................................... Name of Program attending (if multiple modules, indicate that) -------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Dates of Workshops .......................................................................... Full Cost of workshops: ................................. If already paid or made complete arrangements, leave this section incomplete: Enclosed is .................................... for deposit; or, ............................... for payment in full If using Credit Card: Please charge to my credit/debit card, this amount ........................................ for deposit, or ............................... for payment in full. (All funds in US Dollars) If deposit, please charge the balance on my credit/debit card (amount) .............................. on (date).............................. For Credit/Debit Card Payment (MC, VISA, or AmEx only): mail, fax or call with card #, expiration date, SEC #, name on the card, and your billing address for the card. You may, also, pay by check, money order, or via PayPal, via the e-mail method, using admin@sunreed.com' as our e-mail contact, or we can send you an invoice. Card Number .................................................................... Ex Date: ................ 3 Digit SEC code _______ If different: Name on Card: ........................................................................ Billing address: ............................................................................................... ................................................................................................ Date ………………………………… Signature......................................................................................... With my signature I acknowledge and accept the conditions of this workshop & registration as set forth in the information contained in The Center of Light's registration information for this specific program, including any non-refundable deposits and/or program costs. To submit payment on line, go to our Secure page in the registration section of this program, and fill in your contact and charge information, enter the workshop title, cost, or deposit amounts. Your Introduction to Us Name: ____________________________ Please share a little about yourself. There are no pre-requirements for our programs, except where stated We simply wish to know a little about you, your background and interests. Have you attended any of Zacciah’s programs previously? ____ Yes _____ No If less than 3, please tell us which ones (name, location, dates) ____________________________________________________________________________________ _____________________________________________________________________________________
Please tell us a little about your background, your path of spiritual
development, therapeutic background, and/or your path to personal wellness or healing,
and what draws you to this program.
Please give specifics to your development as it relates to this
practice. Please define clearly what
you hope to gain from this program. Please
spend time contemplating your intention and purpose in coming, as well as
questions you have about the nature of this program, and the process you hope to explore in
this practice. By deepening your
conscious awareness of intent and purpose, you open more fully to the potential
of meeting that intent and purpose. We
highly recommend spending some ‘preparation time’ in contemplation of your
purpose, desire, and intent in attending this practice.
нннннннннннннннннннннннннннннннннннннннннннннннннннннннннннннннн(This can be brief or in depth. There are no right or wrong answers: use as many pages as needed) How did you learn about this program? Special requests & Emergency Contact Form for The Center of Light Programs . In case of Emergency, contact: ..................................................................................................... Nature of Relationship: .......................................................................... Address: ....................................................................................................................................... Phone: ....................................................... Cell phone: ................................................................. E-mail address: ..................................................................................... Name and contact of Primary Physician: ________________________________________________________________________ ____________________________________________________________________________ . Special Requirements or medical conditions (Please consult with your licensed physician if there are any medical conditions which might hinder your full participation in this program. We may be unable to honor special requirements, but please let us know them) _________________________________________________________ннннннннннннннннннн____________________________ For programs offering meals: Special Dietary considerations: If you have a special diet, please provide us with that information. Where possible, we will do what we can to accommodate those needs. Please see individual program information or contact us to confirm where that is possible. For programs at SpiritFire: Thus far, the staff at SpiritFire have been very considerate in providing special diets such as vegetarian, gluten or sugar free, etc.... But, they reserve the right to charge you an additional fee as necessary for providing this service. We will inform you if that is so. ALSO, COMMUTERS! We will need to know in advance if you plan to arrive for breakfast or just have lunch and dinner. Lunch and Dinner are included in your cost. Breakfast may be an add’l fee, see your program notes. Other Considerations If there are any other special considerations, including handicap access, please let us know. SpiritFire and NewsBank Main Conference facilities are fully handicapped accessible. Travel Companions, Room Mates Are you traveling with someone else in the program, or wanting to room with someone in particular? Name: _________________________________________________________ Do you wish to room with them? ___ Yes ____No; In one bed ____ in two beds _____ Some programs have an option for one full or queen bed or two single, full or queen beds SpiritFire only has the option of two or three single beds per room. Special Travel Arrangements If you are making special arrangements with SpiritFire for early arrival, late stayover, meals related to those extra stays, or transportation to/from Greenfield MA or other locations due to bus, train, or plane service, please let us know. We can assist with SpiritFire in those arrangements, they will be the final co-ordinators for them, but we wish to know of these arrangements. For other programs, we may be able to assist in your early arrival or late departures. Thank you. Waiver Form for The Center of Light Programs This waiver is provided due to the possibility of our travel to natural or sacred sites. This sometimes occurs in our SpiritFire retreats, Level I training, and is the final program in Level II (touring sites in Vermont,) thus we require it. We do not currently plan on travel in this particular retreat, but it remains a possibility. If you prefer to not sign it until we know if we may travel at this specific program, please bring a copy of this with you to sign at that time. The Center of Light Institute of Sound Healing and Shamanic Studies Zacciah Blackburn, Director P.O. Box 389 Ascutney, VT 05030 . NAME ______________________________________________________ RELEASE AND ASSUMPTION OF RISK I am aware that during the expedition, workshop or activity (hereafter referred to as ‘Activity’) in which I am participating through Zacciah Blackburn, and The Center of Light, in Vermont, (aka The Center of Light Institute of Sound Healing and Shamanic Studies,) and arrangements made through those individuals and organizations, and their associates, I may incur certain risks, including but not limited to, the dangers of traveling in high altitudes, hiking, swimming, mountain climbing, travel by air, boat, automobile, bus or other conveyance, loss or damage to personal property, injury or fatality due to high altitudes, accident or illness in a remote place without medical facilities, water damage due to leaking bags or other containers, exposure to inclement weather, forces of nature and other risks and dangers. In consideration of, and as part of payment for the right to participate in the Activity and the service provided by and arranged for by Zacciah Blackburn, and the Center of Light, and their associates, I hereby assume all risks and release and waive all claims against Zacciah Blackburn, and the Center of Light, and its employees, associates, and representatives, and will hold them harmless from any and all liability, action, cause of action, debts, negligence, claims, demands and damages of every kind or nature whatsoever, whether direct or indirect, contingent, consequential or otherwise, against them, which I now have or which may arise out of, or be brought by a third party in connection with my participation in the Activity or any other activities arranged by, through or with Zacciah Blackburn or the Center of Light, or their associates. This agreement shall serve as a release, assumption of risk and hold harmless provision for me, my heirs, including any minors, participating in these activities. I have read and agree to these terms and conditions. I understand that Zacciah Blackburn and the Center of Light, and their associates, rely on this release in allowing me to participate in these activities. Date _________________________ Signature ______________ If you are participating in any thing other than a 1-2 day indoor program, we will need your Emergency Contact Information Form. We need the Waiver for all retreats and programs which may include travel. |
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The Center of Light Institute of Sound Healing and Shamanic Studies
Zacciah Blackburn, 220 Hidden Glen Rd. , P.O. Box 389 , Ascutney, VT 05030 USA
Phone: (802) 674-9585 Fax: (802) 674-9586 E-Mail info@sunreed.com C 2005-18 Zacciah, The Center of Light
The Center of Light Institute of Sound Healing and Shamanic Studies
Zacciah Blackburn, 220 Hidden Glen Rd. , P.O. Box 389 , Ascutney, VT 05030 USA
Phone: (802) 674-9585 Fax: (802) 674-9586 E-Mail info@sunreed.com C 2005-18 Zacciah, The Center of Light