RETREAT FORM | *heart wide open*

SACRED SOUND, SACRED SILENCE

REGISTRATION

Name *

Email Address *

Phone *

Please list any health concerns or allergies.

REGISTRATION FEE

$395 (due before April 8th)

Please note a $100 deposit is required to hold your space.

(You will not be considered registered until a deposit or full payment has been received.)

PAYMENT *To complete my registration, I will send an e-transfer for $100 (deposit) or $395 (full payement) to

Stay Connected!Yes, I would like to join Heidi's monthly-ish newsletter.

Cancellation and Refunds *I have read, and agree to, the following cancellation policy:Refunds are available until April 1st. No refunds will be issued after April 1st, but you may offer your place to someone else. If for some reason, I (the facilitator) need to cancel the retreat, participants will be refunded in full.

Liability and Consent: *I agree with the following:All events, services and communication, email or otherwise, delivered by Heidi Kalyani and/or *heart wide open* (hereafter “Heidi”), are designed to support you in creating personal transformation. However, these sessions are not professional mental health care or medical care. If you are feeling mentally, emotionally or physically stressed to the point that it is interfering with your ability to function, please seek the help you need from a professional counsellor. In this spirit, before purchasing this session or other services from Heidi, you confirm that you have read and agree to each statement and that you wish to proceed: + I understand that the sessions I will be receiving from Heidi are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that Heidi is not acting as a mental health counsellor or a medical professional. + I understand and agree that I am fully responsible for my well-being during the sessions, and subsequent actions, including my choices and decisions. + I understand that the sessions are not a substitute for counselling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. + I understand that all comments and ideas offered by Heidi are solely for the purpose of aiding me in living a more heart-ful life. I have the ability to give my informed consent, and hereby give such consent. + I understand that Heidi will protect my information as confidential unless I state otherwise in writing. + I hereby release, waive, acquit and forever discharge Heidi, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by Heidi as a result of the advice given by Heidi or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.

SACRED SOUND, SACRED SILENCE

REGISTRATION

Be the change.

Together let’s build a more empowered, connected, compassionate world!