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 Retreat Facilitators Lodging

STEP 1: Fill out Personal, Medical, Insurance & Fitness Information
STEP 2: Select the Retreat of interest by filling in a number next to the retreat.
STEP 3: Fill in Billing information and Credit card info on the secure page. You will be making a 50% deposit by clicking submit at this point.

STEP 1: Mind Over Mountains electronic sign-up form:
Be sure to fill out ONE form per person
First Name
Last Name
Company
Address
City
State
Zip
Country
Email
Phone

Enter in the number of participants above to sign up for this retreat. Your credit card will be debited 50% of the total amount after you click submit and fill in your credit card information on the next secure page.

Personal Information:
Retreat you're signing up for:
Your Age/ Birthday:
Occupation:
Height/Weight
Fitness Level: Excellent, Above Average, Average, Fair or Poor (list one)
T-shirt/Shoe Size:
Emergency Contact Information:
Name:
Relationship to you:
Day Phone/Night Phone
Insurance Information:
There are inherent risks involved in the activities offered within this retreat.
We highly recommend that you obtain health insurance prior to participating.
Insurance Carrier:
Policy Number:
Company Phone:
Company Address:
Travel Information:
We are not responsible for cancellation fees or costs arising from your changed or
cancelled flights, lodging, or other arrangements. We recommend obtaining trip
cancellation insurance from your travel agent.
Arrival Date & Time:
Airline & Flight Number:
Departure Date & Time:
Airline & Flight Number:
Medical Information:
We recommend that you consult your physician regarding your participation
in one of ouradventure retreats. Please contact us if you have ANY questions
regarding your ability to participate.
What is your present state of health?
Do you have any pre-existing medical conditions? If so, please explain:
Please list any medications you are taking and what they are used for:
Do you have any past or present injuries we should know about?
Are you pregnant?
If so, how many months?
Do you have any food allergies or restrictions?
Are you a vegetarian? If so, what do you eat and what don't you eat?
Fitness Information: Please note that each of our retreats y in difficulty (see descriptions).
Make sure you choose a retreat that fits your fitness level. The retreats take place between
7,000 and 12,500 feet
What kind of physical condition would you say you are in? Include activities in which you
participate in and the frequency of each activity.
Other Questions: Please put some time and energy into this section.
What most interests you about our retreats?
What would you like to get out of this experience?
Do you have any experience climbing peaks at elevations above 10,000 ft? If so, when
and where? (No experience is required). What is the highest elevation you have been to?
Do you have any experience rock climbing? Please explain. (No experience is required)
Have you ever participated in an all women's seminar or retreat before?
Do you have any concerns or apprehensions about our adventure retreats?
How did you learn about us?