Today's Date
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Name
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First Name
Last Name
Birthdate
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Phone
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Email
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Emergency Contact
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How did you hear about Soul Journey?
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What brings you to Soul Journey for ceremony?
Dates of retreat you would like to attend:
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June 6, 7, 8
July 18, 19, 20
August 22, 23, 24
September 19, 20, 21
October 17, 18, 19
November 14, 15, 16
December 5, 6, 7
Do you have any spiritual practices or beliefs? (There is no "Right" answer)
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What are your intentions for this ceremony? Consider what you are ready to release or let go of — patterns or beliefs that no longer serve you. Also reflect on what you wish to call in, embody, or create in your life moving forward.
Have you used plant medicines or psychedelics in the past? If yes, please specify which substances you have used and provide details, including any difficult or adverse reactions you experienced.
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Have you ever been diagnosed with any of the following?
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Please share any additional medical conditions and/or diseases that are not listed above.
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Please list any medications, herbs, or recreational drugs you are currently using or have recently stopped using. For prescribed medications, include dosages. Also provide the date of last use and frequency of use. If none, please type ‘None.’
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Are you or could you be pregnant?
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I understand that using other drugs or herbs may pose risks to my health and safety. If I need to discontinue any prescribed medication, I will do so safely and consult my physician as appropriate.
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I am voluntarily participating in a workshop/retreat facilitated by Julie Dunnwald and Keith Garde, which includes shamanic, yogic, meditative, and psychological exercises and practices intended to deepen self-awareness and support psychospiritual growth.
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I acknowledge that certain processes during the workshop/retreat may be physically, emotionally, or mentally demanding, and I accept full responsibility for safeguarding my health and well-being throughout the experience.
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I have fully disclosed all medical and psychiatric conditions that may affect my ability to participate in the workshop/retreat or pose a risk to myself or others, in the Medical Information section of this form.
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I affirm that I have fully disclosed all antidepressants and mood-altering medications I am currently taking in the Medical Information section of this form.
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I acknowledge that the workshop/retreat is not intended as a treatment or therapy for any physical or psychological condition. If I require or desire medical or psychotherapeutic care, I will seek assistance from qualified professionals.
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I release and hold harmless the facilitators, Julie Dunnwald and Keith Garde, from any and all liability, loss, injury, or damage that may arise from or be related to my participation in the workshop/retreat.
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I agree not to pursue any form of litigation or legal action against the facilitators, Julie Dunnwald and Keith Garde, and instead commit to resolving any disputes or disagreements through direct dialogue or mediated negotiation.
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I confirm that the information provided in this form is accurate, complete, and submitted truthfully to the best of my knowledge and ability.
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I confirm that I am in a physical and mental condition suitable for participating in the activities described as part of the ceremony. I understand and accept that I am participating at my own risk, and I agree that Soul Journey and its affiliates shall not be held liable for any accident, injury, or harm that may occur.
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By placing your initials here, you affirm that you have truthfully and fully disclosed all medications, substances (including drugs and herbs) you are currently using or have recently used, as well as any current or past medical or mental health conditions for which you have been diagnosed.
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I acknowledge that participation in the workshop/retreat involves inherent risks, some of which may be unpredictable regardless of my prior health history or experience. I understand that individual responses to the activities may vary and cannot be fully anticipated. Therefore, I accept full responsibility for my health and safety and voluntarily assume all risks associated with my participation. I hereby waive and release any and all claims against the facilitators, staff, and others involved in the workshop/retreat, including claims for injury or damages, on behalf of myself and my heirs. Additionally, I take full responsibility for my conduct during the workshop/retreat, including all interactions with other participants, facilitators, and support personnel.
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