We are thrilled to have you join the Love in Bloom Holistic Adventure Retreat! This is your time to escape, recharge, and reconnect with yourself in a stunning, serene setting. Please complete this form to help us provide the best possible experience and to confirm your acknowledgment of the retreat’s policies and terms.

By completing and submitting this form, I acknowledge and agree to the following:

Client Acknowledgment and Agreement

1. I promise to carefully review this form before the retreat.

2. I confirm that I am over 18 years of age; or, I am the parent or legal guardian of a participant under 18.

3. I wish to participate in wellness activities provided at the retreat, including but not limited to meditation, mindfulness practices, stretching, movement exercises, guided discussions, nature excursions, and cultural experiences.

4. I understand that participation in this retreat does not establish a physician-patient relationship.

5. I acknowledge that I have not been hospitalized for psychiatric reasons within the last three (3) years.

6. I understand that Jessica Chranowski is a Certified Holistic Health Practitioner and certified in Mindfulness Stress Management, and that her role is to facilitate a supportive, holistic experience.

7. I understand that Jessica Chranowski reserves the right to refuse or end a session if my behavior is deemed disruptive, offensive, or unsafe.

8. I understand that retreat activities are not medical diagnoses, treatments, or medical advice, and they do not include prescriptions or psychotherapy.

9. I understand that retreat activities are not reimbursable by insurance.

10. I recognize that this retreat is intended to complement medical practices, not replace them.

Confidentiality

All matters discussed during the retreat are confidential and will be kept in confidence, as required by law.

Cancellation Policy

If you need to cancel your retreat, you will receive a refund minus a $100 deposit if you cancel before February 7, 2025. For cancellations made on or after February 8, 2025, your payments will be credited toward a future retreat hosted by Pure Life Therapy, allowing you to apply your investment to another transformative experience.

Acknowledgment of Risks

I understand that the retreat’s activities, including meditation, movement, stretching, and excursions, involve inherent risks, including but not limited to physical or emotional discomfort or injury.

1. I take full responsibility for monitoring my own limits during all retreat activities.

2. If I have any questions or health concerns, I will notify Jessica so that accommodations can be made.

3. If I am unsure about my physical or emotional fitness to participate, I will consult with my physician before attending the retreat.

Additionally, I understand that the retreat location, Mizata Resort, is approximately one hour from the nearest pharmacy, stores, and hospital. In the event of an emergency, I acknowledge that I will need to consider this travel time for any services required. While the staff at Mizata Resort will do everything they can to assist in such situations, I understand that it is my responsibility to pay for all costs associated with emergencies. Pure Life Therapy is not responsible for any such expenses.

Insurance Recommendation

I acknowledge that Pure Life Therapy does not provide accident, medical, or travel insurance for the retreat. I understand that it is highly recommended to purchase travel insurance to cover unexpected events, emergencies, or cancellations. Travel insurance is highly recommended. Brenna Lew of Avari Travel Agency can help you with an amazing insurance policy. avaritravelagency@gmail.com, ‭+1 (510) 203-2566‬

Release of Liability

On behalf of myself and my representatives (executors, heirs, successors, and assigns), I hereby agree to:

• Waive and Release Pure Life Therapy, its representatives, facilitators, instructors, employees, volunteers, and agents from any and all liability, including personal injury, emotional trauma, property damage, or loss incurred during my participation in the retreat and related activities.

• Indemnify and Hold Harmless Pure Life Therapy and its team from any and all claims, including negligence, arising out of or connected with my participation in the retreat.

• Refrain from bringing legal action against Pure Life Therapy or its representatives in connection with any injuries, damages, or losses I may incur during or in connection with this retreat.

Consent

By typing my name, providing the date below, and clicking the I Consent button at the bottom of this page, I confirm that I have read, understood, and voluntarily agreed to all the terms outlined above.