name *

First Name

Last Name

cell phone # *

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emergency contact phone # *

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*please check all that you need

Climbing harness $10

Climbing shoes $10

RETREATER CONSENT AGREEMENT: *

I agree that I am participating in an Yoga Squirrel Event, during which I will receive information and instruction about rock climbing, yoga, and AcroYoga. I recognize that both rock climbing yoga, and AcroYoga require physical exertion that may be strenuous and may cause physical injury; I am fully aware of and accept full personal responsibility for the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the rock climbing and yoga retreat. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the rock climbing and yoga retreat. In consideration of being permitted to participate in this climbing and yoga retreat, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, past present or future, which I might incur as a result of participating in any climbing, hiking, yoga/AcroYoga practice, workshops and activities at the retreat. In further consideration of being permitted to participate in this climbing and yoga retreat, I knowingly, voluntarily and expressly waive any claim I may have against Yoga Squirrels, Casey Stroud, Sonia Peltzer and any of the staff, for any injury or death caused by their negligence or other acts. I have read the above release and waiver of liability and all terms and conditions and fully understand its contents. By checking the box below, I voluntarily agree to the terms and conditions stated above.

I voluntarily agree to the terms and conditions stated above.

todays date *

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