Backpacking Retreat Questionnaire Name * First Name Last Name Preferred Pronouns Date of Birth * Age at date of the trip * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Is there anything about how you identify that you would like me to know? This could be in a traditional sense, like religion, race, sexual orientation, gender. Or, more general, like parent, artist or anything else you want to share about who you are. Medical Information Emergency Contact * First Name Last Name Relationship to Emergency Contact * Emergency Contact Phone Number * (###) ### #### Do you wear a MedicAlert tag? * Have you ever had a heart attack (coronary, thrombosis, myocardial infarction, etc.)? * Have you ever been told by a doctor that you have high blood pressure, heart murmur, or heart disease? * Have you ever experienced a seizure of any kind? * Do you experience anaphylactic shock from bee stings, other insect bites, or any food sources? * Are you allergic to any drugs, foods, or environmental substances? If yes, please list the severity of the allergy, the drugs you carry, and the symptoms of the allergic reaction. * Please note that epiniphrine is only available by prescription,and thus not something we can stock in our first aid kits. * I will bring my own EPI pen. (we recommend at least two) I have no allergies that cause me to need an EPI pen. Do you have any disabilities or problems with back, hips, knees, or ankles? * Do you have any injuries or medical conditions? If yes please list below. * Are you currently taking any medications prescribed by a physician? If yes, please explain. * Would your doctor approve of your participation in this activity? If you cannot answer confidently, please consult your doctor. * Doctor name and phone number Medical insurance provider and policy number. * Please list any and all medication you are currently taking. * Is there anything else health related that would be helpful for us to know about? Food Do you have any dietary restrictions? * Gluten Free Dairy Free Pescetarian Vegetarian Vegan I have special food needs (i.e. food allergies, 100% vegan & 100% gluten free) and will speak to you about how to accommodate my needs) Flexible, can eat most foods None What do you like to drink in the morning? * Tea NO caffeine Tea with caffeine Coffee black Coffee with cream Other Are there any foods you don't like? Do you have any favorite foods while camping? Is there anything else that would be helpful for us to know about your diet or food preferences as we plan for the trip? Gear & Logistics If you are flying, please provide your arrival and departure flight info, including the date, airline, flight number, and arrival time. If you do not know your flight info yet please make sure to add it to our logistics google doc as soon as you can. When will you be arriving and will you need transportation? * Most likely we will have already discussed this, but please write out what your transportation needs are. Trip insurance (recommended). Please note: Purchasing travel insurance soon after signing up will not only cover any deposits paid but will provide you with a waiver for any pre-existing conditions. * I have purchased trip insurance. I have not purchased trip insurance but plan to. I am not planning on purchasing trip insurance. What camping gear would you like us to provide? (Check all that apply) * Single Person Tent Double Person Tent (If you plan to share with friend or partner) Sleeping Pad Sleeping Bag Backpack None I am sharing a double tent with: Experience The following questions are to help us know you better. You do not have to be "outdoorsy" or a "mediator" to come on retreat. This is to help us know you and the group better so we can support you during our time together. Part of this experience is going offline. How comfortable are you with being offline? * Nervous About It Can't Wait! Not sure yet What is your comfort level outdoors? * I'm comfortable camping Camping makes me nervous but I love the outdoors Just being in nature is out of my comfort zone What is your meditation practice like? * I'm new to the whole meditation thing I've attempted to meditate, off & on I have a somewhat regularly practice I have years of a dedicated practice Media During the retreat I will be taking photos. What level of permission do you give for use of photos in promotional material? You may use any photo I am in. You may use my photo as long as you cannot identify me. (Photos from far away or behind for example) You may not use any photo with me in it. Hopes & Fears Please only share what you are comfortable with. What drew you to sign up for this retreat? * Imagine this retreat was deeply transformational, what would be different in your life three month from now? How about a year from now? * What is your biggest obstacle in life right now? * What is something you would like to let go of during this retreat? * Being on retreat is a mix of alone time and time being with the group. Please describe your comfort level with both being alone and being in a group. * Do you have any fears about going on a backpacking retreat? If yes, what are they? * What's something about yourself that you are excited to bring and share with other on this retreat? What's one of your strengths or gifts? This can sometimes be a difficult question for people, but let it be simple and no need to find the perfect descriptions. It could be something like silliness, a sense of adventure, knowledge, vulnerability etc. How can we best support you on this adventure? Is there anything else you would like us to know about you? Thank you! Join the newsletter Subscribe to get updates on upcoming retreats, workshops and blog posts. Success! Now check your email to confirm your subscription. There was an error submitting your subscription. Please try again. First Name Email Address We use this field to detect spam bots. If you fill this in, you will be marked as a spammer. Subscribe We won't send you spam. Unsubscribe at any time. Powered by ConvertKit
