for all programs and services
Waiver & Emergency Contact Form for The Center of Light Tours and Sacred Journeys First, please insure you have completed our basic Registration Form.The Center of Light, PO Box 389, Ascutney, VT 05030 USA, Phone: 802.674.9585; Fax: 802.674.9586; E-mail: info@sunreed.com Then, please print out or copy and paste into a word document, fill out and mail, or fax with your registration to all programs which include outdoor activities, and all tours and journeys in other countries. All information is kept strictly confidential and shared with no one, except where necessary, and applicable, for our program co-hosts, tour guides, or those authorities required by law. This signed form is a requirement for participation in any outdoor practice, or tour, or journey that occurs outside of the US: For all Sacred Journeys and Tours inside, or outside, of US: EMERGENCY CONTACT INFORMATION: Your Name: _________________________________________________________________________ In case of Emergency, contact: ................................................................................................................. Nature of Relationships: .......................................................................... Address: ......................................................................................................................................................................................................... Phone: ...................................................................................................... Cell phone: .................................................................................. E-mail address: ....................................................................................................................................... Special Requirements (we may be unable to honor special requirements, but please let us know them) ________________________________________________________ _____________________________________________________________________________________________________________________________________ Are you traveling with someone else? Name: _________________________________________________________ If accommodations are provided in this program, do you wish to room with them? _______ Yes _______ No; In one bed __________ in two beds __________ Do you have any special medical conditions? (Please explain, use back if necessary:)______________________________________________________________________ ______________________________________________________________________________________________________________________________________ Name and contact of primary physician: _______________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Please insure you consult with your physician on the nature of, and your participation in this program, if you have any medical condition that may effect, or be effected by, your participation. For all Sacred Journeys or Tours outside of the US: Full Name on as it appears on your Passport ............................................................................................ Passport Number ............................................................. Country of Origin .................................... Citizen of ........................................... Date of Issue ................................................ Expiration Date ................................... Please provide us with two color copies of your passport's first two pages (these fit on one copy page.) These are required by some countries, or hotels in some countries. We keep one copy on record in case of loss. These will be destroyed after the program. For programs over 3 days: Please share a little about your self. There are no pre-requirements for this program. We simply wish to know a little about you. Have you attended any of Zacciah’s programs previously? ____ Yes _____ No If less than 3, please tell us which ones (name, location, dates) ______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ If you have not attended our programs before, please tell us a little about your path of spiritual development and/or personal healing, and what draws you to this program. (Use back if needed, Thank you for your participation!)
I acknowledge I am attending this program to participate in practices for spiritual development. I realize this is not a simple tourist program, although there will be some tourist opportunities. I have read and understand the promotional material of this program, and wish to participate accordingly. Date _________________________________________ Signature ______________________________________________________________ Waiver: 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 Date _________________________ Signature _______________________________________ |
BACK
TO: The
Center of Light
Home Page
Top
of Page
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 2005-11 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 2005-11 Zacciah, The Center of Light