Mind over Mountains, women's adventure retreats

Please print, fill out, and send to us with your non-refundable deposit. You will be required to sign a Release Form prior to participating in Mind over Mountains. (Back to Sign Up Page).

Please print, fill out, and send to us with your non-refundable deposit. (click on: How To Sign Up). You must send your 50% deposit in order to reserve your space. Thank you.

Mind Over Mountains
P.O. Box 486 (regular mail)
546 Hyde St. (FedEx)
Ridgway, CO 81432

PERSONAL INFORMATION:

Name: _________________________________________________________________

Address: _______________________________________________________________

City: _________________________ State: ___________ Country: ________________

Zip Code: __________________________

Phone number: (home)______________________(work)_________________________

Email Address:__________________________________________________________

Which Retreat are you signing up for?________________________________________

Age: _______ Birthday: _____________Occupation: ___________________________

T-shirt size: ______________________ Shoe size:_____________________________

Height:_________________ Weight: _______________________

Fitness Level (circle one) - Excellent, Above Average, Average, Fair, Poor

EMERGENCY CONTACT INFORMATION: (required)

Phone #____________________ Relationship to you__________________________

Phone number (day)____________________ (night)_________________________

INSURANCE INFORMATION: Insurance is required in order to attend one of our retreats.

Carrier ______________________________________ policy #___________________

Phone number_______________________ Address____________________________

TRAVEL INFORMATION: We recommend acquiring travel insurance in the event that you have to cancel your retreat under unexpected circumstances.

Arrival Date: ______ Arrival Time: _______ Airline: __________ Flight # __________

Departure Date: _________ Depart. Time: _________ Airline: ________ # _________

MEDICAL INFORMATION: We recommend that you consult your physician regarding your participation in one of our adventure retreats. Please contact us if you have ANY questions regarding your ability to participate.

What state your present level of health:______________________________________

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Do you have any pre-existing medical condition? If so, Please explain:

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Please list any medications you are on and what they are used for:

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Do you have any past or present injuries we should know about? __________________

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Are you pregnant? ___________ If so, how many months? ___________________

Do you have any food allergies or restrictions? If so, please explain:

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Are you a vegetarian? If so, what do you eat and what don’t you eat?

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FITNESS INFORMATION: Please note that each of our retreats vary in difficulty (see descriptions) make sure you choose a retreat that fits your level of fitness. The retreats takes 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.

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QUESTIONS: Please put some time and energy into this section:
1) What most interests you about our retreats?

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2) What would you like to get out of this experience?

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3) Do you have any experience rock climbing? Please explain. (no experience is required)

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4) 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 ever been to?

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5) Have you ever taken an all women’s seminar or retreat before?

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6) What are some of your favorite interests and hobbies?

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7) Do you have any concerns or apprehensions about our adventure retreats?

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8) Do you have other comments or questions?

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