RELEASE OF LIABILITY AND ASSUMPTION OF ALL RISKS - ONE DAY RETREAT

STATEMENT OF PSYCHOLOGICAL AND HEALTH CONDITION

The information that you share on this form is kept confidential.

I, Rosanne JG Kloeg, owner of Rose of the Islands LLC dba AlohaRose Retreats, want to offer you a magical retreat experience!

Activities on this one-day retreat can be, but are not limited to:

walks with an approximate maximum of 2.5 hours
walks in the sun, in mountainous areas, on sand and lava (smooth and rough); walks in rain are unlikely but possible.
standing in the bed of a truck, holding on to a pole, while (slowly) driving in rough terrain (think of sun, wind, holes and mounds of sand) for about 20 minutes.

To create the best fitting retreat activities for you and the other women in the group, it is important for both of us and the group, to have the most accurate information about your psychological and health condition. Thank you for writing down your statement of psychological and health condition.

Name:

Age:

Sex:

Telephone:

1- Please list any physical disabilities, allergies, conditions, past injuries or any limitations that could limit your participation on the journey.

2- What medications are you taking or will you take during the one-day retreat? Please list any precautions and side effects.

3- Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological and/or psychiatric conditions? If yes, how long ago was the diagnosis and when was your last episode? How do you deal with an episode?

4- 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? If yes on one or more, please tell me what situations trigger you, how it looks when you are triggered and how you deal with it.

5- If I should warrant immediate medical attention on this journey, I hereby grant permission to the medical personnel, selected by Rosanne Kloeg, owner of AlohaRose Retreats, and representatives, to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted.

6- If I should warrant immediate medical attention on this one-day retreat, I hereby grant permission to the medical personnel, selected by Rosanne Kloeg, owner of AlohaRose Retreats, and representatives to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.

7- If I should warrant immediate medical attention on this one-day retreat, I hereby grant permission to the physician selected by Rosanne Kloeg, owner of AlohaRose Retreats, and representatives to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me.

8- I agree to adhere to the decision by Rosanne Kloeg, owner of AlohaRose Retreats, and representatives, regarding the suitability of my participation in the excursion.

9- I declare this statement is correct to the best of my knowledge.

Please initial after each item and then sign below:

________________________________ ________________________________

Participant's signature Date