[ARCHIVE] APPLY | Aurum Retreats

First Name*

Last name

Gender

Female

Male

Other

Date of Birth:*

Address*

Phone Number*

Email Address*

Insurance Carrier

Insurance Policy Number

Primary Physician Name and Number

In Case of Emergency, Please Notify:*

Phone*

Relationship*

Do you have any known medical conditions or allergies? (If yes, please provide details)*

Are you currently taking any prescription medications? (If yes, please list)*

Do you have any dietary restrictions or preferences?

Have you ever participated in a medicine retreat before? (If yes, please provide details)*

What is your primary intention for participating in this retreat?*

What are your expectations for the retreat experience?

Please share any previous experiences with meditation, mindfulness, or plant medicines:

Have you experienced any significant life changes or challenges in the past year?*

How did you hear about this retreat?*

Is there anything else you would like us to know or any specific questions or concerns you have?

I understand that this medicine retreat involves participation in activities that may be physically and emotionally challenging. I certify that all information provided in this application is true and complete to the best of my knowledge. I am aware of the potential risks associated with participating in this retreat and will adhere to all safety guidelines and recommendations provided by the organizers. I consent to undergo any necessary medical evaluation or treatment in the event of a medical emergency. I understand that the retreat organizers will make every effort to ensure my safety and well-being.*

I Agree

I understand that I must be over 21 to participate in Aurum's programs (unless given written permission from a parent or guardian). I understand that I must submit a valid ID proving my identity and age. I understand that Aurum reserves the right to do a background check using the information on my ID. *

I agree

I understand that in order to participate in programs with Aurum, I must fill out the application and be approved for the Private Membership Association (PMA), found at the bottom of this page, and in the email sent upon completion of this application.*

I understand

In consideration of acceptance of my application by Golden Path Aurum PMA, I acknowledge that participating in a retreat involves certain risks (some of which I may not fully appreciate) and that injuries, death, property damage or other harm could occur to me or others. I accept and voluntarily incur all risks of any injuries, damages, or harm which arise during or result from my participation in the retreat, including any associated travel, regardless of whether or not caused in whole or in part by the negligence or other fault of Golden Path Aurum PMA, and/or its or their departments, trustees, affiliates, employees, officers, agents or insurers ("Released Parties"). I waive all claims against any of the Released Parties for any injuries, damages, losses or claims, whether known and unknown, which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties. I release and forever discharge the Released Parties from all such claims. I agree to indemnify and hold the Released Parties harmless from all losses, liabilities, damages, costs or expenses (including but not limited to reasonable attorneys' fees and other litigation costs and expenses) incurred by any of the Released Parties as a result of any claims or suits that I (or anyone claiming by, under or through me) may bring against any of the Released Parties to recover any losses, liabilities, costs, damages, or expenses which arise during or result from my participation in the retreat, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties. I have carefully read and reviewed this Waiver, Release And Hold Harmless Agreement. I understand it fully and I execute it voluntarily.*

I agree

I have read and agree to the Privacy Policy*

I agree

I have read and agree to the Cancellation Policy*

I agree

I understand that there are next steps, which can be found at the bottom of this page.*

I understand

Applicant's Name/Virtual Signature*

Retreat Application

Next Steps

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