2023 Soul Purpose Retreat Intake Form — Third Eye Tribe of Venus Rising

Select the event that you are attending

EMERGENCY CONTACT INFORMATION

Relationship to Emergency Contact

Email of Emergency Contact

DIETARY REQUIREMENTS

Please list any food allergies, sensitivities, etc.

LODGING PREFERENCE

To calculate your rate for the retreat: $615 Program Fee + Accommodations * $615 base fee covers the retreat program and all meals * Final rate is determined by your lodging preferences (listed below)

Select Accommodations

MEDICAL HISTORY INFORMATION

Tell us about any significant illnesses, injuries, and/or surgeries you have experienced

Do you experience any physical limitations that we should know about that might impact your participation in physical activities? If so, please explain.

Do you experience Chronic Illness?

Do you smoke Tobacco?

Do you drink Alcohol?

Any known allergies?

Are you currently on any Medications? If yes, please list them.

Do you have any Specific Health Requests?

Please inform us if you have or have had any Mental Health challenges. Please note previous/current addictions, psychiatric treatments, and hospitalizations that you wish to share. This information will remain confidential within the core team.

LIFE INFORMATION

Age

Relationship Status

Relationship Status- how long?

Children? (If yes, what are their ages?)

Parents Living? (If yes, what are their ages?)

List Significant Others, including Names, Ages and Relationships

LIFE EXPERIENCE

Place of Employment

How long?

Completed Degrees, Certifications, Trainings

Have you attended any previous Events with Third Eye Tribe, Star Wolf, a Shamanic Breathwork Facilitator, Venus Rising, or a Venus Rising Congregation? (S.H.I.P., Shamanic Breathwork Facilitator Skills, etc.)

Please tell us about your vision for your healing and training goals and what you hope gain from this experience.

THIRD EYE TRIBE RELEASE FORM

Would you like to receive the Third Eye Tribe newsletter?

I realize that SHAMANIC BREATHWORK® is a powerful experiential tool for accessing my own inner healer and can greatly intensify my transformational process. Through the process of deep core breathing and chakra-attuned music I will embark on a journey into the soul. Because this process can bring up intense emotions and strong physical experiences, I have been advised that it is not recommended for those with certain types of cardio-vascular problems, epilepsy, recent surgery, pregnancy, or psychosomatic, mental health, other physical limitations, or emotional problems. I hereby acknowledge that I have no such problems or conditions as listed above, or any other physical, mental or emotional conditions that would prevent me from participating in SHAMANIC BREATHWORK®. I have fully disclosed my physical, emotional, and mental background to the staff of Third Eye Tribe of Venus Rising prior to my participation in the process. I realize that the staff, assistants, agents and/or volunteers of Third Eye Tribe of Venus Rising is here only as a guide to my process, and none of the staff, assistants, agents and/or volunteers is here to replace any form of traditional mental or physical health treatment or spiritual modalities. I have talked with any and all mental and physical health care professionals that I believe would be necessary to assess whether I would be an appropriate person to participate in the SHAMANIC BREATHWORK ® Process, based upon my physical, emotional, and mental health history and current condition(s). I attest that there is no reason why I should not be able to participate. To this purpose, I voluntarily participate in the SHAMANIC BREATHWORK® Process and I release and hold harmless The Third Eye Tribe of Venus Rising Association for Transformation, including members of the staff individually and any assistants, agents and/or volunteers for any and all acts or omissions which may be grounds for legal action, including but not limited to acts or omissions which may constitute ordinary negligence. This release is intended to apply to all acts or omissions whether they be related to the grounds, premises, staff, assistants, agents and/or volunteers and any related individuals or groups. I accept full responsibility for my own physical, mental, emotional and spiritual well being. I know of no physical or mental health reason why I should not participate in this workshop and I have fully explored this issue with the staff at Third Eye Tribe of Venus Rising as well as any other medical and/or legal advisors I deem appropriate. I have asked all the questions I may have and have received answers adequate so that I freely and knowingly waive all liability as set forth above without reservation of any kind. I further attest and acknowledge that this release is intended and shall apply to my heirs, beneficiaries and assigns. I hereby acknowledge that I understand that the activities I engage in during this workshop or Shamanic Mystery Tour may stretch my comfort zone, and might be perceived by me as physically, emotionally, or psychologically challenging, uncomfortable and may trigger anxiety (ex. Sweat Lodge). I understand that there may be terrain that is potentially hazardous, including but not limited to: streams, ponds, pools, waterfalls; rocky, steep, uneven trails and grounds; steps and stairs. I understand that this workshop may be held on land home to a variety of wildlife, including snakes, bobcats, raccoons, foxes, skunks, coyotes and bears. I take full responsibility for any injury sustained when on or about said areas, and I agree to hold harmless Third Eye Tribe of Venus Rising and all facilitators for any injury or causes of action of every nature sustained while in or about the building(s) and premises in which the sessions are conducted, or during any walks or on or off-site excursions in which I participate. Lastly, During the Course of Third Eye Tribe's Workshops, there may be photos, audio recordings, and videos taken of teachers and participants. These photos, videos, and recordings may include discussions, including questions by participants and answers from facilitators. Personal sharing and process groups will not be recorded or photographed. These photos, audio recordings and videos will be used to support the work of Lisa Asvestas and Third Eye Tribe of Venus Rising. They will be posted on Facebook and other social media and in our newsletters. By completing this form, I acknowledge that I understand I may be included in photos, audio recordings and videos used in the above described manner by Third Eye Tribe and I hereby give my permission for such use. No further request for authorization of use will be issued by Third Eye Tribe of Venus Rising.

SOUL PURPOSE RETREAT - INTAKE FORM