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THE FIFTH ELEMENT RETREAT

Participant Intake & Self-Discovery Questionnaire

Personal Information

Information to be used for astrological, numerological, and human design insights and will be provided to each participant for self-discovery purposes

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Health & Safety

7. Do you have any chronic illnesses, medical conditions, or physical limitations? (Yes/No)
Yes
No
8. Do you have any allergies (food, environmental, medication)? (Yes/No)
Yes
No
9. Do you have any dietary restrictions or preferences? (Vegetarian / Vegan / Gluten-Free / Other)
No
Vegetarian
Vegan
Gluten-Free
Other
10. Are there any activities you are unable to participate in due to health reasons? (Yes/No)
Yes
No
11. Do you take any medications we should be aware of? (Yes/No)
Yes
No

Mental & Emotional Wellness

(This helps us ensure appropriate support and safety during group experiences.)

12. Do you have any mental health conditions that may affect your participation? (Yes/No)
Yes
No

Lifestyle & Safety

13. Do you agree to refrain from drugs, alcohol, or weapons during the Retreat? (Yes/No)
Yes
No
14. Do you agree to minimize or limit cell phone use during the Retreat to the best of your ability? (Yes/No)
Yes
No

Self-Discovery & Intentions

Emergency Contact

Consent & Acknowledgment

By completing this questionnaire, I acknowledge that The Fifth Element Retreat may use my responses to provide a safe, supportive, and personalized experience. I agree to follow retreat guidelines, including minimizing cell phone use and refraining from drugs, alcohol, and weapons.

THE FIFTH ELEMENT RETREAT

Participant Waiver & Liability Agreement

Safety Acknowledgment & Participant Responsibility

I acknowledge that participation in The Fifth Element Retreat includes activities such as nature immersion, water-based activities, movement practices, breathwork, fire elements, and wellness modalities, which may involve inherent risks.

I confirm that I have disclosed all relevant medical conditions, injuries, allergies, and limitations, and that I am physically and mentally able to participate or will modify my participation as needed.

I agree to follow all instructions and safety guidelines provided by facilitators, staff, and practitioners at all times, including the proper use of safety equipment where applicable.

I understand that activities take place in a natural outdoor environment and may involve exposure to uneven terrain, weather conditions, water, and fire elements. I acknowledge that participation is voluntary, and I accept full responsibility for my health, safety, and well-being throughout the retreat.

I agree to conduct myself in a respectful and safe manner and understand that failure to follow guidelines may result in removal from activities. I further acknowledge that The Fifth Element Retreat maintains a substance-free environment, and I agree to refrain from the use of drugs, alcohol, or weapons during my participation.

I am not a U.S. or foreign participant or a pro, semi-pro, or carded athlete.

By signing this form, I confirm that I have read, understood, and agree to these safety conditions.

Participant Information

1. I Understand the Risks.

I understand that participation in The Fifth Element Retreat includes activities such as hiking, water-based activities, breathwork, fire elements, movement practices, and optional healing modalities.

I acknowledge that these activities may involve physical exertion and carry a risk of injury, illness, or discomfort, and I voluntarily accept these risks.

2. My Health & Responsibility.

I confirm that I am physically and mentally able to participate in this retreat, or I will modify participation as needed.

I agree to inform staff of any medical conditions, allergies, injuries, or limitations that may affect my participation.

3. Emergency Medical Authorization.

In the event of a medical emergency, I authorize The Fifth Element Retreat staff to seek medical attention on my behalf, including contacting emergency services if required.

4. Release of Liability.

I agree not to hold The Fifth Element Retreat, its owners, facilitators, staff, or volunteers responsible for any injury, illness, loss, or damage that may occur during my participation.

5. Physical Activity & Outdoor Environment.

I understand that participation may involve physical activity such as walking, hiking, breathwork, outdoor movement, and water-based experiences.

I acknowledge that this retreat takes place in a natural outdoor environment and may include exposure to weather conditions, uneven terrain, water, fire elements, and wildlife.

6. Respectful Participation.

I agree to follow all retreat guidelines, listen to facilitators, and contribute to a safe, respectful, and supportive environment for all participants.

7. Photos & Media Consent.

Consent to photos and videos taken during the retreat being used for promotional or educational purposes.

Photos & Media Consent
I consent
I do not consent

8. Health Awareness.

I understand there is always a risk of illness or injury when participating in group activities and outdoor experiences. I agree to take responsibility for my own wellbeing and follow any health precautions provided.

9. Agreement.

I confirm that I have read and understood this waiver, and I voluntarily agree to participate in The Fifth Element Retreat under these terms.

Date
Year
Month
Day
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