Registration Form

Personal Information

Participant's Name —

Address —

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Gender — ---MaleFemale

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Emergency Contact

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Relationship with participant —

Phone —

Alternative Phone —

If you have medical insurance please indicate the company name and policy number that we may use in case of an emergency:

Specific Requirements

Dietary Requirements

 vegetarian vegan allergic or sensitive to dairy/lactose allergic or sensitive to nuts allergic or sensitive to wheat/gluten allergic or sensitive to soy others (please specify below)

Please let us know about any other specific requirements you may have regarding accommodation, meals, mobility assistance, special medical conditions (including allergies), recent medical treatments, etc.

Ride Sharing

 Yes, I am interested in offering a ride or get a ride from another participant.

If offering a ride, where are you departing from? What time?

If you choose this option, we will email you with ride share participant information a weeks prior to the retreat. Note that transfer from Washington DC is included in our fee. If you prefer to come with your own car and it’s willing to give other participants a ride we will cover your fuel expenses.

Liability Waiver

I agree to indemnify, defend and hold harmless anyone associated with organizing this event, from and against any claim, action, cause of action, liability, loss, damage, or expense, including attorney's fees, to the extent caused in whole or in part by the negligent or willful act or omission of an act of myself. I agree to take full responsibility to the extent permitted by the laws and constitution for any and all damage to Pyne Mountain Farm premises, facilities, personnel of the group's attendees, and anyone associated with organizing this event. Anyone associated with the organization of this event, is not responsible for any loss or damage, no matter how caused, to any samples, displays, equipment, or personal effects brought into the venue by myself. I agree to grant permission to use my name or any video, picture, or audio recording taken of me during the retreat if I do not clearly indicate privacy contraints on the matter.