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Women’s Weekend Class Signup Form
Women's Weekend Class Selection
Thank you for registering for classes for our 2019 Women's Weekend Getaway! We look forward to another great weekend!
Step 1 of 7
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Women's Weekend Class Sign Up 2019
We are excited to have you join us this year. Classes work on a first come, first serve basis. Classes can only be secured once final balances are paid for the weekend. Class descriptions can be found in the Women's Weekend Information Packet on our website. These can help you with your decisions. We look forward to seeing you. If you have any questions about sign ups please don't hesitate to contact us.
Have you paid your balance in FULL?
*
YES
Please note that if you have not paid your balance in full for the weekend we cannot assign you your classes.
Contact Information
Name
*
First
Last
Phone
Email
*
Class sign-up for Saturday, September 28th
Please refer to the class descriptions that can be found in the Women's Weekend Information Packet included in your email. These can help you with your decisions to help you pick your classes. We do our best to create a schedule for you that has as many of your first choices for classes as we can. However, classes fill on a first-come first-serve basis and many have a cap to maintain the high quality of the classes, so please indicate a 2nd and 3rd choice for each class time. You do not need to sign up for every class session. The weekend is what you make of it. For this reason you will see "R&R" (Rest and Relaxation) as an option for each class session. Also, keep in mind that there are additional services outside of classes that can be booked when you arrive for the weekend.
Class 1: 8:45 - 9:45
Tully Lake Hike (1,2 & 3), Zip Line, Mindful Yoga, Fill Your Cup, Biking, Riflery, Kayaking, Advanced Candling, Rest and Relax (no class)
Class 1: First Choice
*
...Select Classes
Tully Lake Hike (Trip - 3 blocks )
Zip Line (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Fill Your Cup (Peter Simmonds
Biking (Takodah Staff)
Riflery (Takodah Staff)
Kayaking (Takodah Staff)
Advanced Candling (Takodah Staff)
Rest and Relax (No Class)
Class 1: Second Choice
*
...Select Classes
Tully Lake Hike (Trip - 3 blocks )
Zip Line (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Fill Your Cup (Peter Simmonds
Biking (Takodah Staff)
Riflery (Takodah Staff)
Kayaking (Takodah Staff)
Advanced Candling (Takodah Staff)
Rest and Relax (No Class)
Class 1: Third Choice
*
...Select Classes
Tully Lake Hike (Trip - 3 blocks )
Zip Line (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Fill Your Cup (Peter Simmonds
Biking (Takodah Staff)
Riflery (Takodah Staff)
Kayaking (Takodah Staff)
Advanced Candling (Takodah Staff)
Rest and Relax (No Class)
Class 2: 10:00 - 11:00
Tully Lake Hike (1,2 & 3), Zip Line, Card Stamping, Under the Hood, The Story of You, Ax Throwing, Canoeing, Tie Dye, Rest and Relax (No Class)
Class 2: First Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Zip Line (Takodah Staff)
Card Stamping (Leslie Percival)
Under the Hood (Caleb Perham)
The Story of You (Peter Simmonds)
Ax Throwing (Takodah Staff)
Canoeing (Takodah Staff)
Tie Dye (Takodah Staff)
Rest and Relax (No Class)
Class 2: Second Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Zip Line (Takodah Staff)
Card Stamping (Leslie Percival)
Under the Hood (Caleb Perham)
The Story of You (Peter Simmonds)
Ax Throwing (Takodah Staff)
Canoeing (Takodah Staff)
Tie Dye (Takodah Staff)
Rest and Relax (No Class)
Class 2: Third Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Zip Line (Takodah Staff)
Card Stamping (Leslie Percival)
Under the Hood (Caleb Perham)
The Story of You (Peter Simmonds)
Ax Throwing (Takodah Staff)
Canoeing (Takodah Staff)
Tie Dye (Takodah Staff)
Rest and Relax (No Class)
Class 3: 11:15 am - 12:15
Tully Lake Hike (1,2 & 3), Do Terra Essential Oils, Broadway Basics, Under the Hood, Cat Walk, Outdoor Cooking, Wood Carving, Archery, Rest and Relax (No Class)
Class 3: First Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Do Terra Essential Oils (Michelle Davis)
Broadway Basics (Takodah Staff)
Under the Hood (Caleb Perham)
Cat Walk (Takodah Staff)
Outdoor Cooking (Takodah Staff)
Wood Carving (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 3: Second Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Do Terra Essential Oils (Michelle Davis)
Broadway Basics (Takodah Staff)
Under the Hood (Caleb Perham)
Cat Walk (Takodah Staff)
Outdoor Cooking (Takodah Staff)
Wood Carving (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 3: Third Choice
*
..select class
Tully Lake Hike (Trip - 3 blocks)
Do Terra Essential Oils (Michelle Davis)
Broadway Basics (Takodah Staff)
Under the Hood (Caleb Perham)
Cat Walk (Takodah Staff)
Outdoor Cooking (Takodah Staff)
Wood Carving (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 4: 2:45 - 3:45 pm
Wine Tasting (4 & 5), Beer Tasting (4 & 5), Self Defense, Giant Swing, Card Stamping, Advanced Candling, Rest and Relax (No Class)
Class 4: First Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Deihim)
Giant Swing (Takodah Staff)
Card Stamping (Leslie Percival)
Advanced Candling (Takodah Staff)
Photo Basics (Kim Phyfe)
Rest & Relax (no class)
Class 4: Second Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Deihim)
Giant Swing (Takodah Staff)
Card Stamping (Leslie Percival)
Advanced Candling (Takodah Staff)
Photo Basics (Kim Phyfe)
Rest & Relax (no class)
Class 4: Third Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Deihim)
Giant Swing (Takodah Staff)
Card Stamping (Leslie Percival)
Advanced Candling (Takodah Staff)
Photo Basics (Kim Phyfe)
Rest & Relax (no class)
Class 5: 4:00 - 5:00 pm
Wine Tasting(4 & 5), Beer Tasting(4 & 5), Self Defense, Meet Your Guardian Angels, Essential Oils, Broadway Basics, Rest and Relax (No Class)
Class 5: First Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Delhim)
Meet your Guardian Angel (Carmen Carrigan)
Essential Oils (April Reynolds)
Broadway Basics (Takodah Staff)
Photo Walk (Kim Phyfe)
Rest and Relax (No Class)
Class 5:Second Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Delhim)
Meet your Guardian Angel (Carmen Carrigan)
Essential Oils (April Reynolds)
Broadway Basics (Takodah Staff)
Photo Walk (Kim Phyfe)
Rest and Relax (No Class)
Class 5: Third Choice
*
..select class
Beer Tasting (Trip Blocks 4 & 5)
Wine Tasting (Trip Blocks 4 & 5)
Self Defense (Arian Delhim)
Meet your Guardian Angel (Carmen Carrigan)
Essential Oils (April Reynolds)
Broadway Basics (Takodah Staff)
Photo Walk (Kim Phyfe)
Rest and Relax (No Class)
Class sign-up for Sunday, September 29th
We do our best to create a schedule for you that has as many of your first choices for classes as we can. However, classes fill on a first-come first-serve basis, so please indicate a 2nd and 3rd choice for each class time.
Class 6: 8:45 - 9:45
Giant Swing, Mindful Yoga, Sweating to the Oldies, Riflery, Canoeing, Block Printing, Tie Dye, Archery, Rest & Relax (no class)
Class 6: First Choice
*
..select class
Giant Swing (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Sweating to the Oldies (Takodah Staff)
Riflery (Takodah Staff)
Canoeing (Takodah Staff)
Block Printing (Takodah Staff)
Tie Dye (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 6: Second Choice
*
..select class
Giant Swing (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Sweating to the Oldies (Takodah Staff)
Riflery (Takodah Staff)
Canoeing (Takodah Staff)
Block Printing (Takodah Staff)
Tie Dye (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 6: Third Choice
*
..select class
Giant Swing (Takodah Staff)
Mindful Yoga (Shae Sterrett)
Sweating to the Oldies (Takodah Staff)
Riflery (Takodah Staff)
Canoeing (Takodah Staff)
Block Printing (Takodah Staff)
Tie Dye (Takodah Staff)
Archery (Takodah Staff)
Rest and Relax (No Class)
Class 7: 10:00 - 11:00
Giant Swing, Pure Romance, Happy Rocks, Ax Throwing, Rock Climbing Wall, Multi-Vine, Kayaking, Riflery, Rest and Relax (No Class)
Class 7: First Choice
*
..select class
Giant Swing (Takodah Staff)
Pure Romance (Bernice Rankins)
Happy Rocks (Sara Norman)
Ax Throwing (Takodah Staff)
Rock Climbing Wall (Takodah Staff)
Multi-Vine Course (Takodah Staff)
Kayaking
Riflery (Takodah Staff)
Rest and Relax (No Class)
Class 7: Second Choice
*
..select class
Giant Swing (Takodah Staff)
Pure Romance (Bernice Rankins)
Happy Rocks (Sara Norman)
Ax Throwing (Takodah Staff)
Rock Climbing Wall (Takodah Staff)
Multi-Vine Course (Takodah Staff)
Kayaking
Riflery (Takodah Staff)
Rest and Relax (No Class)
Class 7: Third Choice
*
..select class
Giant Swing (Takodah Staff)
Pure Romance (Bernice Rankins)
Happy Rocks (Sara Norman)
Ax Throwing (Takodah Staff)
Rock Climbing Wall (Takodah Staff)
Multi-Vine Course (Takodah Staff)
Kayaking
Riflery (Takodah Staff)
Rest and Relax (No Class)
Class 8: 11:15 - 12:15
Living As An Empowered, Multi Vine, Voyageur Crossing, Benefits of CBD, Guided Mediation, Kayaking, Pamper Pole, Block Printing, Rest and Relax (No Class)
Class 8: First Choice
*
..select class
Living as an Empowered (Carmen Harrigan)
Multi Vine (Takodah Staff)
Voyage Canoe (Takodah Staff)
Guided Mediation (Sara Norman)
Kayaking (Takodah Staff)
Pamper Pole (Takodah Staff)
Block Printing (Takodah Staff)
Benefits of CBD
Rest & Relax (No Class).
Class 8: Second Choice
*
..select class
Living as an Empowered (Carmen Harrigan)
Multi Vine (Takodah Staff)
Voyage Canoe (Takodah Staff)
Guided Mediation (Sara Norman)
Kayaking (Takodah Staff)
Pamper Pole (Takodah Staff)
Benefits of CBD
Block Printing (Takodah Staff)
Rest & Relax (No Class).
Class 8: Third Choice
*
..select class
Living as an Empowered (Carmen Harrigan)
Multi Vine (Takodah Staff)
Voyage Canoe (Takodah Staff)
Guided Mediation (Sara Norman)
Kayaking (Takodah Staff)
Pamper Pole (Takodah Staff)
Block Printing (Takodah Staff)
Benefits of CBD
Rest & Relax (No Class).
Interest in other choices and pampering services
You will sign up for these services through the weekend on a first come first serve basis. Preferences here will allow us to plan ahead based on interest. Majority of services have been volunteered so please support these additional services with tips where applicable.
Pampering and Wellness Services
Life Coaching
Stargazing Voyageur Canoe (Saturday 10:00pm - Free)
Tarot Reading
Therapeutic Massage
Sound Bath Chakra Balancing
Reiki
Soothing Sessions
Women's Weekend Health History Form
This information is vital for your own Health and Safety during the weekend. This online form now replaces the standard Health and Release Form that was brought with you. You do not need to bring a copy with you for the weekend.
Participant Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact Information
Primary Emergency Contact Name
*
First
Last
Relationship
Primary Emergency Contact Phone
*
Primary Emergency Contact Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Secondary Emergency Contact Name
First
Last
Relationship
Secondary Emergency Contact Phone
Secondary Emergency Contact Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Health History
Is the participant covered by family medical/hospital insurance?
Yes
No
Cardholders Name
Carrier/Plan Name
Group number
Name of primary care physician
First
Last
Phone of primary care physician
Are there any physical, emotional, or behavioral issues Camp should be aware of? Recent or ongoing medical treatment?
*
Yes
No
If YES, please explain below.
Allergies. Please describe reaction and management of the reaction.
Dietary Restrictions
*
None
Vegetarian
Vegan
No Gluten
No Dairy
Other
Other Dietary Restrictions
Please describe any additional dietary restrictions.
Describe any restrictions to activity - What cannot be done, necessary limitations or adaptations and why.
Authorization: I attest that the above health information provided is accurate and complete. I hereby grant permission to qualified instructors or other medical personal to secure and administer treatment, including hospitalization, for me in an emergency. This completed form may be photocopied for use on trips out of camp.
*
Yes - I understand and agree
No - I do not agree
Women's Weekend Statement of Risk and Release
Please read carefully before accepting and agree to each statement.
Photo/Media Release: I authorize the reproduction, publication and use by the Takodah YMCA for promotional, marketing, public relations, or any other purpose, any pictures or likeness of me taken during the YMCA Camp Takodah Programs.
*
Yes - I understand and agree
No - I do not agree
I, the undersigned, am aware that the Camp Takodah Outdoor Programs are designed to be challenging-physically, mentally, and emotionally. I understand that the Camp Takodah Outdoor Programs involve land and water-based activities in an outdoor setting.
*
Yes - I understand and agree
No - I do not agree
I understand that certain risks and dangers are inherent and exist within the rigorous physical activities in which, I, the undersigned, will be participating in throughout the experience.
*
Yes - I understand and agree
No - I do not agree
I acknowledge that while the program and its staff has carefully designed the activities and makes every reasonable effort to reduce all dangers, hazards, and perils associated with these activities, the risk of injury or disability cannot be totally eliminated.
*
Yes - I understand and agree
No - I do not agree
I understand this form and my Health/Medical Information Form must be completed and returned to Camp Takodah prior to participation in any activities. I, the undersigned, am not under a physician's care for any undisclosed condition that bears upon my fitness to participate in Camp Takodah Outdoor Programs.
*
Yes - I understand and agree
No - I do not agree
I understand my personal duty and responsibility to learn and follow the safety standards, guidelines, and procedures established by the instructors. I will make the instructors aware at any point during the activity in which I question my knowledge of these standards, guidelines, and procedures, or my ability to participate.
*
Yes - I understand and agree
No - I do not agree
Electronic Signature
*
By my electronic signature below, I hereby warrant that I: (1) have read the above statements and understand the risks associated with participation in Camp Takodah Outdoor Programs, and (2) am aware of and have met all of the prerequisites to participation in this program. This includes having completed and returned the Health/Medical Information Form and assuming risk/accident insurance coverage, and (3) give consent to the instructors or other medical personnel to treat me in an emergency situation.
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Thank you so much and we can't wait for you to join us this Fall for another great Women's Weekend.