Healing Medicine Retreat Complete your Attendee Info Form

Name(Required)

First Last

Do you have a name or nickname you prefer to be called?

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number On WhatsApp(Required)

If you do not yet use WhatsApp, please download the app and add your number. This is used for all in -Costa Rica communications.

Passport and Travel Documentation

Citizenship(Required)

Passport Number(Required)

Place of Issue

Date of Issue

Birth Date

Arrival Flight Info

Arrival Airline(Required)

Arrival Flight Number(Required)

Airport Final Leg Leaves From(Required)

Arrival Date(Required)

Arrival Time (In CST)(Required)

:

CST is Costa Rica time, your airline should already give you this time in CST.

Departure Flight Info

Departure Airline(Required)

Departure Flight Number(Required)

Airport Departure Leg Arrives To(Required)

Departure Date(Required)

Departure Time (In CST)(Required)

:

CST is Costa Rica time, your airline should already give you this time in CST.

How can we make your trip delightful and safe?

Any dietary restrictions or preferences?

We can cater to all of your needs, please be specific

Are you willing or plan to share a room?(Required)

Yes, please assign me a roommate

Yes, I have a roommate in mind

No, traveling solo on this one and want my own room

Name of Roommate(Required)

What can we do to make your stay unforgettable?

This can be items you'd love in your room, amenities, or whatever is on your mind!

Are you interested in any of the following add-ons during your visit to Con Smania CR?

Massage - 60 minutes for $130

Massage - 90 minutes for $170

Plant Medicine Ceremony

Bodhi Tree Excursion (Included)

These are possibilities to be arranged and will discuss one-on-one either before or upon arrival.

Emergency Contact Name(Required)

Relation(Required)

Emergency Contact Phone(Required)

Terms and Releases

As an attendee at a retreat at Con Smania CR, you are in a relationship with both your retreat leaders, Stephanie Ball, Jennifer Graffice, and Heather Story and the retreat center itself, owned and operated by a US Florida-based corporation Con Smania Collective LLC.

Likeness and Media Release From Con Smania CR(Required)

THIS AGREEMENT is made between Con Smania Collective LLC (“us” or “we” or “our”) and the submitter of this info form ("you" or “your”) (collectively the “Parties”).

You grant us the right to use your image, visual likeness, portrait, photograph, video and sound recordings (collectively referred to as "Likeness") in all forms and media.

Your Likeness will be used for the purposes of content, marketing, and social media posts (the “Material”).

The Material may be published on any of the following channels:

Blog posts written by us, to be published on https://consmaniacr.com or https://consmaniacollective.com;
Email campaigns written by us and sent to lawfully obtained email addresses;
Photos taken by us or our hired photographers, to be published on our websites and social media channels;
Video filmed by us, to be published on YouTube and promoted on our websites and social media channels; and,
Mentions on our social media channels.
We agree to use your Likeness only in connection with the above uses and for no other purpose without your prior written consent.

You represent and warrant that you have the right to grant us the above-mentioned rights without obtaining the permission of, or making any payments to, any third party or entity. This authorization and release shall inure to the benefit of our legal representatives, licensees, and assigns. You hereby release us from, and agree not to sue for, any claim or cause of action, whether known or unknown, for libel, slander, invasion of right of privacy, publicity or personality, or any other claim or cause of action, based upon or relating to the use of the Material or the exercise of any of the rights referred to herein. You agree to indemnify and hold us harmless, along with our officers, directors, shareholders and employees, from and against any liabilities, losses, claims, demands, costs (including, without limitation, attorneys' fees) and expenses arising in connection with any breach or alleged breach of this agreement.

You acknowledge that, in the event of any breach by us, the damage, if any, caused will not be irreparable or otherwise sufficient to entitle you to seek injunctive or other equitable relief. Your rights and remedies will be strictly limited to the right, if any, to recover damages in an action at law, and you will have neither the right to rescind or terminate this agreement or any of our rights hereunder, nor the right to enjoin the production, exhibition, or other exploitation of the Materials.

This Agreement shall be construed and enforced according to the laws of and in the courts of the State of Florida and any dispute under this Agreement must be brought in this venue and no other.

I agree to the Likeness and Media Release

Scroll through to read the entire terms in order to proceed

Release of Liability and Assumption of All Risks(Required)

Please read carefully, this is a legally enforceable waiver of rights

Assumption of Risks

I acknowledge that I have voluntarily applied to participate in the retreat designated on this application. I am voluntarily participating in the retreat with knowledge that travel to foreign countries and/or the remote areas visited by this trip involves numerous risks and dangers including, but not limited to, a risk of illness, injury or death, which may be caused by: forces of nature, civil unrest, terrorism, road conditions, injuries inflicted by animals, insects, reptiles or plants, trails, hotels, vehicles, boats or other means of conveyance which are not operated nor maintained to standards common in the United States; high altitude accident, accident or illness without access to means of rapid evacuation or the availability of medical supplies; the lack of adequacy of medical attention once provided, and negligence on the part of Con Smania Collective LLC, Jill Sessa, their affiliated organizations and their shareholders, employees, teachers, volunteers or other agencies. I acknowledge that the enjoyment and excitement of foreign travel/adventure travel is derived in part from the inherent risks incurred by travel and activity beyond the accepted safety of life at home or work, and that these inherent risks and the corresponding enjoyment and excitement contribute to the reason for my voluntary participation on this trip.

Release

AS LAWFUL CONSIDERATION for being permitted by Con Smania Collective LLC, to participate on such trips and activities, I hereby agree that I, my heirs, legal representatives or any member of my family will not make a claim against or sue Con Smania Collective LLC, Jill Sessa,, or any of their affiliated agents, shareholders, employees, teachers or volunteers, for bodily injury, death, emotional trauma or property damage resulting from my participation in the tour or expedition.

I therefore release and discharge Con Smania Collective LLC, Jill Sessa, and their agents, shareholders, employees, teachers and volunteers from and against any and all liability arising from my participation in the tour or expedition even though that liability may arise out of negligence or carelessness on the part of Con Smania Collective LLC, Jill Sessa, or their affiliate agents, shareholders, employees, teachers or volunteers.

If any portion of this agreement is unenforceable, the remaining portions shall remain in full force and effect. Under no circumstances shall Con Smania Collective LLC be liable to any retreat participant for more than the land cost of the trip applied for on this document. I waive any charge-back rights and, in the event of dispute, requests for a refund will be made using the procedures described under “Cancellation and Refunds” as stated in the Terms and Conditions for this trip. All applications are subject to acceptance by Con Smania Collective LLC. Upon acceptance of my application, this agreement shall be deemed to have been entered into at Green Cove Springs, Florida and shall be construed according to the laws of the State of Florida. In the unlikely event a legal dispute should arise involving any subject matter whatsoever, I agree that the exclusive venue for any legal action shall be Green Cove Springs, Florida, USA.

Travel Insurance

We recommend Trip Cancellation insurance or Trip Interruption insurance for this trip. Travel insurance is designed to reimburse you for non-refundable expenses in case of a trip cancellation as well as for other provisions such as: missed flight connections, medical expenses/emergency assistance coverage (if something happens to you personally), baggage & personal effects coverage (if they are lost or stolen), baggage delay (if your bags do not arrive with your flight and you have to buy clothing, and personal items) which could possibly be very costly. Please note that insurance policies vary tremendously and have various critical exclusions. We recommend you choose carefully based on your personal situation.

Knowing and Voluntary Execution

I have carefully read and fully understand the contents of this agreement as well as all the conditions as stated under the heading "Terms and Conditions" including those conditions regarding responsibility borne by trip participants and conditions regarding cancellations and refunds. I am aware that this is a release of liability and a legally binding and enforceable contract between myself and Con Smania Collective LLC and I sign it of my own free will.

I hereby accept any and all risks of illness, injury, emotional trauma, or death and verify this statement by checking this box.

I hereby accept the above release paragraphs and verify this statement by checking this box.(Required)

I Accept

I hereby accept any and all risks associated with my refusal to purchase the insurance suggested in the above paragraph by checking this box.(Required)

I Accept

Signature of Agreement to the Release of Liability and Assumption of All Risks(Required)

Comments

This field is for validation purposes and should be left unchanged.

Help Us Help You!

Attendee Info Form

Passport and Travel Documentation

Arrival Flight Info

Departure Flight Info

How can we make your trip delightful and safe?

Mental and Physical Health

Terms and Releases