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LUMINOUS MIND RETREAT WITH TINA RASMUSSEN – REGISTRATION SURVEY

This is a rigorous retreat and requires solid physical and mental health. Despite the wholesome aspiration for deep practice, there are times when a 2-week retreat is not necessarily suitable, and participants should focus on shorter retreats at that time. Because of this, we are asking you to respond to some questions that will assist the teacher in determining if this retreat is a good fit for you at this time.

Tina Rasmussen is the only one who will view your responses.

Last Name*

Email*

PHYSICAL HEALTH

Have you undergone any of the following in the last 6 months?*

Surgery

Cancer Treatment

Long Covid

Chronic Fatigue Syndrome

Drug/Alcohol Withdrawal

Other — any other acute or chronic condition that could limit your physical strength, energy and stability during this period of intensive practice

NONE

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Items undergone last 6 months

If you answered yes to any of the above, please provide additional details here for the teacher, including any treatment you may currently be undergoing:*

MENTAL/PSYCHOLOGICAL HEALTH

Have you ever experienced any of the following:*

Complex PTSD

Bi-polar disorder

Psychosis

Delusional disorder

Losing touch with reality

Paranoia

Other — any other acute or chronic condition that could limit your mental and emotional strength, energy and stability during this period of intensive practice

If you are in therapy, is your therapist aware of your intention to participate in a 2-week retreat?

NONE

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Items experienced db

If you answered yes to any of the above, please provide additional details here for the teacher, including any treatment you may currently be undergoing.*

I hereby certify that the above statements are true and accurate.*

Please sign in the box provided

Participation Agreement and General and Medical Waiver and Release of Liability

The undersigned (I) will participate in a Luminous Mind Sangha retreat, held at Cloud Mountain Retreat Center. This retreat is not a substitute for therapy or treatment for illness, whether emotional or physical, and I am not attending this retreat to seek such therapy or treatment.

I take full responsibility for my participation in the event. In consideration for and in exchange for the right to participate in this retreat, I waive, release, and agree to hold harmless Luminous Mind Sangha, its officers, directors, employees, agents, licensees, retreat leaders, staff, and volunteers, and Cloud Mountain, its officers, directors, employees, agents, licensees, staff, and volunteers, against any costs, fees, expenses, liability, or claims, whether medical, psychological, or legal, arising from any conduct or activity on this retreat, or its effects. This release and waiver includes but is not limited to: psychotic breaks, confusion, emotional disturbance, mental health issues, depersonalization, injury, death, theft, loss, or other liability, regardless of any act or omission by Luminous Mind Sangha and/or Cloud Mountain, no matter how caused.

I hereby assume all risks of injury or harm to my person, or damage to my property or mental health and psychological stability, arising from any cause related to, or arising from, this retreat, whether known or unknown, whether expected or unexpected, and I waive and release all claims I may have against Luminous Mind Sangha and/or Cloud Mountain.

I sign this release on behalf of myself and my heirs, assigns, executives, guardians and personal representatives. This release shall be effective whether the course of any injury, harm, or loss was known or unknown and whether the injury or loss was contemplated or uncontemplated at the time of signing the release. I will indemnify Luminous Mind Sangha and/or Cloud Mountain for any claims against it as a result of my participating in this event.

I assume and will bear the costs of all risks that may be created, directly or indirectly, by any such condition. Luminous Mind Sangha and Cloud Mountain are not and will not be responsible for harm and I promise not to bring legal action against Luminous Mind Sangha and/or Cloud Mountain. I have been truthful in all of my statements in my retreat application and student questionnaire for this retreat, to the best of my ability.

Print Name*

Waiver Signature

VERIFICATION CODE: