Name

First Name

Last Name

Phone

(###)

###

####

Experience with cleansing?

None

Some

A lot

Check yes if you agree

If I need to cancel after payment, I will receive credit to attend a future Living Wild retreat, there will be no money refunded.

Yes

No

Check yes if you agree

I actively choose to engage with this seasonal activation of nutrition and lifestyle practices. I commit to listening deeply to my body and attuning to my needs. My Body is my highest guide for self care and nourishment. I recognize that all the information provided at the retreat is to be practiced of my own choice and dedication to cellular activation. I love, nourish and deeply care for my beautiful vessel.

Yes

No

Check yes if you agree

I agree that by attending this retreat, I am opening myself up to new energies and experiences and will come wiith an open mind. I agree to pay the invoice within one week of receivng

Yes

No

Waiver *

In consideration of being allowed to participate in the programs and associated offerings of the Wellness Retreat with, Emily Werner, programs, at The Secret Garden Estate you hereby (1) agree to assume full responsibility for any and all injuries or damage which are sustained or aggravated by you in relation to programs of and release, discharge, protect, defend, indemnify and hold harmless Emily Werner, their affiliates and related entities, officials, staff, representatives, officers, directors, shareholders, employees, agents, assigns and consultants and each of their respective successors and assigns and all others, from and against, any and all claims, actions, liabilities, damages and expenses (including reasonable attorneys’ fees and court costs) whatsoever to the fullest extent allowed by law, arising out of or in any way related to your participation in the Retreat programs and (3) represent that you (a) have no medical or physical condition that would prevent you from properly participating in any of the Retreat programs, including seasonal cleanse , (b) do not have a physical or mental condition that would put you in any physical or medical danger, and (c) have not been instructed by a physician to not participate in physical exercise. You acknowledge that if you have any chronic disabilities or conditions, you are at risk in participating in the Retreat, and should not be participating. ~

I read through and agree to participate

I do not agree to participate