Intake, Medical Release, Program Agreements, and Letter of Intent Form

Evolve In Nature Program Intake Form, Medical Release, Program Agreements, and Letter of Intent

This form is for the following program

What is your legal first and last name?

What name do you go by?

What are your pronouns?

Phone

(###)

###

####

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please list your emergency contact(s) including their first and last name, their relation to you, and their phone number.

Please list all medications you are currently taking. List each one by name, along with the reason for use and the dosage for each.

Have you spoken to your treating physician or therapist about participating in this program and do they support your participation?

Is there any reason this program would not be safe for you to participate in either for physical, psychological, or other reasons?

Do you have any injuries? If so, please describe.

Do you have any current illness? If so, please describe.

Do you have any known allergies? If so, please explain.

This is a sober program. This includes no recreational drugs, no alcohol, no vaping, or smoking of any kind, no psychedelics, or any other mind-altering substances. By checking this box below, you agree to uphold this policy during the full duration of the trip, including travel to and from the group.

Yes

Consent for PHI Transmission via Unsecure Means

The information in this form will be sent directly to Megan Newton and reviewed by program guides or leaders.

I understand that by clicking 'Submit' I am sending personal health information through an internet connection/source that may or may not be secure and I agree to doing so.

Cancellation and Refund Policy

The fee for the program is non-refundable, including in cases where you have to cancel for unexpected or unfortunate reasons. Your guides reserve your spot and plan for your attendance.

I agree to the cancellation and refund policy

Intention

Please write your intention letter for attending this program. This may include what is inspiring you to attend, what your primary focus is during this time of self reflection, what you want to end or begin, how you hope this experience will support your life personally and community, etc.

Today's Date

YYYY

E-Signature (full name)

By checking this box, I agree and understand that my electronic signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to my responses.

Evolve In Nature
1200 28th Street
Suite 205
Boulder, CO 80305
(303) 993-7787

Evolve In Nature Program Intake Form, Medical Release, Program Agreements, and Letter of Intent

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