2026 Women's Sacred Mountain Retreat - Medical Information, Release of Liability, and Non-Refundable Deposit Form

Name

Date of Birth

Participant Phone

Participant Email

This address will receive a confirmation email

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship ex. spouse, sister, etc.

Emergency Contact Phone

In Case of an emergency, please list your current medications:

Dietary Disclosures

Please check all that apply:

Gluten Free Dairy Free Vegetarian Vegan (no dairy) No Restrictions

Other Dietary (please specify)

Allergies

Do you carry an EpiPen or other emergency medications?

Yes No

Explain above (other emergency medications)

Medical Information

Please list any relevant medical conditions and/or physical limitations

Anything Else We Should Also Know

Consent and Acknowledgement

CLICK HERE: Consent and Acknowledgement Form

Enter Name Here: I consent and Acknowledge that I have read and agree to the 2026 Women's Retreat Rules

Photographs may be taken during the retreat.

Images of me to be used for promotional materials.

Yes, I give permission. No, I do not give permission.

Deposit Payment

Non-Refundable Deposit: Due By June 15th 100.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

2026 Sacred Women’s Mountain Retreat

August 19 - August 22, 2026 (Wednesday - Saturday)

El Tesoro Retreat Center
Located outside of Woodland Park, Colorado

Dear Retreat Attendees,

As you may know, the elevation of the retreat venue is 9000 feet!

Therefore, we are asking you to fill out and sign this Medical Information, Release of Liability, and Non-Refundable Deposit Form.

Please complete and submit this form to us by Monday, June 15th

$100 Non-Refundable Deposit: Due By Monday, June 15th

*Credit or Debit Card payments. *No cash or checks accepted.

Early Bird Pricing by Thursday, June 25th:
$50 Per Night Single Bed Fee
$100 Per Night Double / King Bed Fee

Late Registration starts Friday, June 26th and ends Friday, July 10th:
$60 Per Night Single Bed Fee
$120 Per Night Double / King Bed Fee

$125 Retreat Fee (Includes activities and food) - Due no later than July 10th for all participants.

For more information contact: Lorilei Bourell or Rose Salcetti at: womenssacredretreat@gmail.com

2026 Women's Sacred Mountain Retreat - Medical Information, Release of Liability, and Non-Refundable Deposit Form

Description

Please Fix the Following