Wild Mind Intensive: A Mythopoetic Journey for Black & Brown Leaders

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* These fields are required

1 Welcome

2 People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

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3 Participant Info

Preferred Name and Pronouns
Phone *
Gender *	This information is used to help the guides understand the demographics of this program.
Birth Date *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
How did you hear about us?
Please list how you heard about us?
Policies & Procedures *	I accept Animas Valley Institute's policies & proceduresPlease review our policies & procedures here. PLEASE NOTE: These policies have changed as of May 2022
Are you planning on attending this program with a friend, partner or family member? *	Yes No
If attending with a family member, partner or friend, we ask that you room/camp separately, avoid sitting next to each other in group, and not “compare notes” throughout the program. Additionally, your guides will be notified and your participation is subject to their discretion and approval. If not approved, the Animas office will reach out to you. Unfortunately, we do not allow family members, partners or friends to attend Animas Quests and other advanced immersions together. Click here for our FAQ *	I acknowledge

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4 Health Information

Height *	(ft, in)
Weight *	(lbs)
Special Diet *
Diet Notes *
Please list any current medical conditions *
Are you currently (or within the past two years) receiving treatment from any health care professional(s) for any physical condition? *
If yes, please list and explain. If you are under the care of any health care provider(s), do they approve of you engaging in this activity? *
Are you currently taking any medication(s) or supplement(s)? *
If yes, please list the medications and supplements and their purpose. *
Are you currently (or within the past two years) receiving treatment from any health care professional(s) for any psychological reason? *
If yes, please list your current psychological conditions for which you receive treatment. Does your provider approve of you engaging in this activity? *
Are you currently taking any psychiatric medications? *
If yes, please list the medication(s) and their purpose. *
Do you plan to alter any medication routines prior to or during any portion of this program? *
Have you ever had an eating disorder (anorexia/bulimia nervosa, binge eating, etc)? *
If yes, please list dates, type of disorder and where you are with it now. *
Have you ever had an addiction? *
If yes, please describe the condition, any treatment, and dates of treatment. When was the last time you participated in addictive behaviors? *
Have you ever been diagnosed with heart disease? *
Have you ever had a heart attack? *
If yes, please list date and explanation. *
Do you have a heart murmur or pacemaker? *
Have you ever been diagnosed with high blood pressure? *
Please list your usual blood pressure. *
Please list your resting pulse rate if you know it. *
Have you ever experienced a seizure of any kind? *
If yes, please explain *
Have you ever had a lung disease (asthma, emphysema, etc)? *
Do you use a CPAP machine, supplemental oxygen or have difficulty breathing at high elevations? *
Are you hypoglycemic or diabetic? *
Do you have hemophilia? *
Do you wear a medic alert bracelet? *
If yes, please list what it is for *
Please list the date of your most recent tetanus shot *
Do you have any allergic reactions to any environmental substances, food or drugs? *
If yes, please list the substances and describe the severity and type of the reaction. *
Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? *
If yes, please explain *
How would you rate your present degree of physical fitness? *
Do you have any disabilities of the back, knees, hips or ankles? *
If yes, please explain *
If you walked on level ground for a mile at an average pace, would you get out of breath, have chest pain, leg pain, or develop muscle fatigue? *
If yes, please explain *
Are you pregnant? *
Approximately how many nights have you slept outside (in a tent, tarp, or otherwise)? *
When was the last time you camped outside (vs RV camping)? *
Can you set up your own tent and/or tarp? *
What else do you feel we should be aware of or that you are concerned about regarding your physical ability and condition? *
Is there anything else you feel we should be aware of or that you are concerned about regarding your emotional condition and history to help us be of better service to you? Please share even if you feel it isn’t likely to be relevant. *
Emergency Contact #1 Info *	Please list your emergency contacts' name, relationship to you & cell phone number.
Emergency Contact #2 Info *	Please list your emergency contacts' name, relationship to you & cell phone number.
Do you have health insurance? *	•Please note that in the United States it is essential to have your own health insurance. If you are an American, please ensure that you do so. An emergency room visit can cost up to $4,000 while an overnight hospitalization may cost close to $10,000 USD. •If you are a visitor from another country, please consider obtaining travel insurance from your own country to cover any expenses related to the exorbitant US health care system costs.
If yes, please provide information below *	Please list health insurance company name, company phone number & policy number
Mental Health Provider Name and Phone Number *	This information will only be used in the event of an emergency.
Medical Provider Name and Phone Number *	This information will only be used in the event of an emergency.

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5 Liability Release Form

Liability Release Form *	I agree that this release form applies to all applied programsParticipant Agreement, Release and Assumption of Risk Animas Valley Institute, PO Box 1020, Durango, CO, 81302 ~ 970-259-0585 In consideration of the services of Animas Valley Institute, their agents, owners, officers, volunteers, participants, employees, independent contractors (including, but not limited to: Bill Plotkin, Sabina Wyss, Jeffrey Allen, Geneen Marie Haugen, Rebecca Wildbear, Gene Dilworth, Mary Marsden, Nate Bacon, Doug Van Houten, Sage Magdalene, Peter Fonken, Brian Stafford, Laura Gunion, John Lynch, Jules Howatt, Kate Joyner, Palika Benton 'Rewilding', Laura Blakeman, Sara McFarland, Julian Norris, Kent Dobson, Dan Dolquist, Bell Selkie Lovelock, Christie Diamond, Tracey Forest) and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "AVI"), I hereby agree to release, indemnify, and discharge AVI, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows: a) I acknowledge that hiking, camping and backpacking entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, but are not limited to, slipping and falling; falling objects; water hazards; exhaustion; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia (heat related illnesses), heat exhaustion, sunburn, dehydration, exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; accidents or illness can occur in remote places without medical facilities and emergency treatment or other services rendered; consumption of food or drink; equipment failure; improper lifting or carrying; my own physical condition, and the physical exertion associated with this activity. Furthermore, AVI employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction. b) I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary and I elect to participate in spite of the risks. c) I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless AVI from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of AVI's equipment or facilities, including any such claims which allege negligent acts or omissions of AVI. d) Should AVI or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. e) I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have. f) In the event that I file a lawsuit against AVI, I agree to do so solely in the state of Colorado, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. g) I acknowledge that all Animas Valley Institute programs are not intended as therapy, a substitute for therapy or trauma work. In addition, our guides are not licensed mental health therapists. COVID-19 ASSUMPTION OF RISK AND LIABILITY WAIVER In consideration of the services of Animas Valley Institute, their agents, owners, officers, participants, guides, employees, apprentices, volunteers, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “AVI”), I, the undersigned, hereby agree to release, waive, indemnify, discharge, and covenant not to sue AVI, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative, and estate as follows: I acknowledge that I have voluntarily elected to attend an in-person Animas Valley Institute (“AVI”) program during the novel coronavirus COVID-19 pandemic and understand gathering in groups poses risk of transmission of COVID-19. I acknowledge I have been following the recommended protocols to limit exposure to COVID-19 in the two weeks leading up to the program, in order to protect everyone involved with this program. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending the program and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 during the program may result from the actions, omissions, or negligence of myself and others, including, but not limited to, AVI guides (including AVI assistants, apprentices, clan leaders, staff or other AVI agents), program participants, and passerbys. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at the program ("Claims"). I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of AVI, its employees, contractors, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any AVI program.
Signature *	By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against AVI on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. If you wish to sign this form with an electronic signature (type in your name below) and you agree that your electronic signature is your signed acknowledgment that you have read and agree to all of the stipulations listed above.
Your City and State *	This will be shared with other participants and guides for carpooling and ridesharing purposes.
Travel Plans (if known)

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