Registration Form
Rocksprings Registration
To fill it out this form, first copy and paste it to your email, then fill it out and send it to:
First name
Last name
Address including Zip
Phone number
Email address
Are you Eighteen or older?
Mode of transportation to and from Rocksprings?
Date and time of planned arrival: (Please plan to arrive no later than 5:00 PM)
Date and time of planned departure:
Do you have any physical conditions that will limit your ability to participate fully in the Daily schedule?
Please describe any special diets or other accommodations that would be needed:
Please list any life threatening allergies regarding food, medicine, insect bites, etc.:
Emergency Information:
Person to be notified in case of an emergency:
Name
Address
Telephone(s)
Relationship
If that person is unavailable, please notify:
Name
Address
Telephone(s)
Relationship
Please list any underlying medical or psychological conditions (and medications that you may be currently taking) that a doctor should know about in case of an emergency.
Have you ever had any emotional or psychological problems that meditation or solitude may complicate?
Meditation:
How long have you been meditating?
About how many hours do you practice each week?
What types of meditation have you done in the past?
What kind of meditation are you doing now?
Are you getting good results?
What would you like to achieve?
Please indicate your agreement to abide by the Eight Precepts (as mentioned in “Guidelines” tab) while you are at Rocksprings: I agree ( )
Please indicate your agreement to present Rocksprings with a signed “Hold Harmless Agreement” (see below) upon your arrival. I agree ( ).
Last name
Address including Zip
Phone number
Email address
Are you Eighteen or older?
Mode of transportation to and from Rocksprings?
Date and time of planned arrival: (Please plan to arrive no later than 5:00 PM)
Date and time of planned departure:
Do you have any physical conditions that will limit your ability to participate fully in the Daily schedule?
Please describe any special diets or other accommodations that would be needed:
Please list any life threatening allergies regarding food, medicine, insect bites, etc.:
Emergency Information:
Person to be notified in case of an emergency:
Name
Address
Telephone(s)
Relationship
If that person is unavailable, please notify:
Name
Address
Telephone(s)
Relationship
Please list any underlying medical or psychological conditions (and medications that you may be currently taking) that a doctor should know about in case of an emergency.
Have you ever had any emotional or psychological problems that meditation or solitude may complicate?
Meditation:
How long have you been meditating?
About how many hours do you practice each week?
What types of meditation have you done in the past?
What kind of meditation are you doing now?
Are you getting good results?
What would you like to achieve?
Please indicate your agreement to abide by the Eight Precepts (as mentioned in “Guidelines” tab) while you are at Rocksprings: I agree ( )
Please indicate your agreement to present Rocksprings with a signed “Hold Harmless Agreement” (see below) upon your arrival. I agree ( ).
(All information is held in strict confidence)
_____________________________________________________________________________
_____________________________________________________________________________
IMPORTANT:
All new guests are required to have a signed Hold Harmless Agreement on
file at Rocksprings. Please print out the Hold Harmless Agreement
below, read it carefully, sign it, and bring it with you to Rocksprings.
Hold Harmless Agreement
ACKNOWLEDGMENT OF RISK AND HOLD HARMLESS AGREEMENT
I hereby acknowledge that I have voluntarily chosen to participate in the Dhammabucha Rocksprings meditation program (hereinafter called “program”).
I understand the risks involved in the program. I recognize that the program and its activities involves risk of injury and I agree to accept any and all risks associated with it, including but not limited to property damage or loss, minor bodily, mental, or psychological injury, severe bodily, mental, or psychological injury, and death.
Furthermore, I recognize that participation in the program involves activities and risks incidental thereto, including but not limited to: transportation related to the program, training, practices, hazardous and primitive living conditions, exposure to plants, insects and animals, some of which may be potentially dangerous, limited availability of medical assistance because of the remote location, and the possible reckless conduct of other participants. I am voluntarily participating in the program with the knowledge of the risks involved and hereby agree to accept any and all inherent risks of property damage, bodily, mental, or psychological injury, or death.
In consideration of my participation in the program and to the fullest extent permitted by law, I agree to indemnify, defend and hold harmless Dhammabucha Rocksprings, its trustees, officers, directors, employees, agents, volunteers and assigns from and against all claims arising out of or resulting from my participation in the program. “Claim” as used in this agreement means any financial loss, claim, suit, action, damage or expense, including but not limited to attorney’s fees, attributable to bodily injury, mental, or psychological injury, sickness, disease or death, or injury to or destruction of tangible property including loss of use resulting there from. In addition, I hereby voluntarily hold harmless Dhammabucha Rocksprings its trustees, officers, directors, employees, agents, volunteers and assigns from any and all claims, both present and future, that may be made by me, my family, estate, heirs or assigns.
I hereby expressly agree to indemnify, defend, and hold harmless Dhammabucha Rocksprings , its trustees, officers, directors, employees, agents, volunteers and assigns for any claim arising out of or incident to my participation in the program. I also understand that Dhammabucha Rocksprings does not provide any medical or dental insurance or life insurance to cover bodily, mental, or psychological injury, illness or death, nor insurance for personal property damage or loss, nor insurance for liability arising out of my negligent acts or omissions; and I acknowledge that I am completely responsible for my own insurance to cover these expenses.
I further understand that this assumption of risk and hold harmless is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that if any portion hereof is held invalid, I agree that the balance shall, notwithstanding, continue in full legal force and effect.
I agree that this acknowledgment of risk and hold harmless is effective for as long as I participate in the program and includes all subsequent and future visits to the Dhammabucha Rocksprings.
I have read and understand this acknowledgement of risk and hold harmless.
Participant’s Name (Last, First, M.I.):____________________ _________________________________ _______
Participant’s Signature:__________________________________________Date:_________________________
Email Address: ______________________________________________________________________________
Emergency Contact/Emergency Phone:___________________________________________________________
IF THE PARTICIPANT IS UNDER THE AGE OF 18, THE SIGNATURE OF A PARENT OR GUARDIAN IS REQUIRED BELOW.
Parent Name/Signature/Date:___________________________________________________________________