Name
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First Name
Last Name
Email
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What draws you to this work and how did you hear about it?
Tell us a little about your experience with creative work, somatic practices, dream work and inner work.
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RELEASE, WAIVER AND INDEMNITY
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In consideration of the acceptance to participate in a Creative Dream Work Workshop at Huron Substation, I accept full responsibility for the risks to my person and psyche and to my property by accident, injury, illness, loss, damage or otherwise while attending and participating in any of the activities and I agree I am attending and participating voluntarily.
1 - I for myself, my heirs, executors, successors and assigns, hereby release, waive and forever discharge Kim Gillingham, Roams and any other person in any way associated with any activity at this event and from all claims, demands, and damages, expenses, actions and causes of action, whether in law or in equity in respect of any accident, injury, illness, or loss or damage to my person or property howsoever caused arising directly or indirectly because of or in any way connected with my attendance at and participation in the programs, whether prior to, during, or subsequent to the program and notwithstanding that the same may be contributed or occasioned by my negligence.
2 - I consent to receive medical treatment in the event of injury, accident and/or illness during the program.
3 - I understand that this is an educational program only.
4 - I consent to hold in confidence any and all information shared by others.
Emergency Contact
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First Name
Last Name
Emergency Contact Phone
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Country
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Medical Conditions / Allergies / Medications:
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