Help Us Help You! Please complete the Attendee Info Form below Attendee Info Form Give us all the deets! 1About You2Travel Docs3Health4Releases 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 DocumentationCitizenship(Required) Passport Number(Required) Place of Issue Date of Issue MM slash DD slash YYYY Birth Date MM slash DD slash YYYY Arrival Flight InfoArrival Airline(Required) Arrival Flight Number(Required) Airport Final Leg Leaves From(Required) Arrival Date(Required) MM slash DD slash YYYY Arrival Time (In CST)(Required) Hours : Minutes AM PM AM/PM CST is Costa Rica time, your airline should already give you this time in CST.Departure Flight InfoDeparture Airline(Required) Departure Flight Number(Required) Airport Departure Leg Arrives To(Required) Departure Date(Required) MM slash DD slash YYYY Departure Time (In CST)(Required) Hours : Minutes AM PM AM/PM 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 specificAre 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) Mental and Physical HealthThis information is confidential and helps us to provide our safe environment, please be detailed.Please list any physical disabilities, allergies, conditions, past injuries or any limitations we need to know about.(Required)What medications are you taking or will you take during the retreat? Please list any precautions and side effects.(Required)Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological conditions?(Required)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?(Required)If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the medical personnel contacted to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted.(Required) Yes, permission granted No, I do not authorize access to my medical records If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the medical personnel in attendance or contacted to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.(Required) Yes, permission granted No, authorization can only be granted by my emergency contact. I understand that in the case of being unable to reach my emergency contact, Good Samaritan procedures will be put into effect and care will be given to the best of the person's ability. If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the physician selected by Con Smania CR representatives to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me.(Required) Yes, permission granted No, authorization can only be granted by my emergency contact. I understand that in the case of being unable to reach my emergency contact, Good Samaritan procedures will be put into effect and care will be given to the best of the person's ability. I agree to adhere to the decision by Con Smania CR representatives, regarding the suitability of my participation in any activities or excursions while on the retreat, either on-site or off-site.(Required) Yes, I agree No, I do not agree and recognize this may be grounds for removal from the retreat. All statements I have made in this document are accurate and correct to the best of my knowledge at the time of submission. I agree to update the staff of Con Smania CR with any additional information pertinent to my attendance at the retreat.(Required) Yes, all is correct. No, I do not agree and recognize this may be grounds for removal from the retreat. Terms and ReleasesAs 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) I agree to the Likeness and Media Release Scroll through to read the entire terms in order to proceedRelease of Liability and Assumption of All Risks(Required)Please read carefully, this is a legally enforceable waiver of rights 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)PhoneThis field is for validation purposes and should be left unchanged.
