Statement Of Psychological and Health Conditions

Statement of Psychological and Health Conditions
All information provided on this form is kept confidential

1. Please list any physical disabilities, allergies, conditions, past injuries or any limitations that could limit your participation on this retreat.

2. What meditations are you taking or will you take during the retreat? Please list any precautions and side effects.

3. Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological conditions?

This helps us in case of an emergency

Do you have a history of sexual or physical abuse? Do you have a history of substance abuse? Do you have a history of suicidal tendencies or a suicide attempt?

If I should warrant immediate medical attention on this retreat, I hereby grant permission to the medical personnel, selected by Costa Rica Retreat, to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions.

If I should warrant immediate medical attention on this retreat, I hereby grant (or refuse) permission to the medical personnel, selected by Costa Rica Retreat to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.

If I should warrant immediate medical attention on this retreat, I hereby grant (or refuse) permission to the physician selected by management at Costa Rica Retreat and representatives to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me.

I agree to adhere to the decision by management of Costa Rica Retreat, the retreat leader or other representatives, regarding the suitability of my participation in this retreat

I declare this statement is correct to the best of my knowledge.

Please type in your name below as an electronic signature