Let’s make this as easy as 1, 2, 3! 1—Fill out your form2—Book Your Tickets3—Join Us November 4th Name * First Name Last Name Email * Birth Date * MM DD YYYY Birth Time, mark 8:00 am if you don't know. * Hour Minute Second AM PM Birth Place Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (By submitting your number and clicking SEND you give consent to text communication from Amy Leiter. Message and/or data rates may apply. * Country (###) ### #### Passport Documentation * Passport Documentation * Passport Documentation * Date of Issue MM DD YYYY Passport Documentation * Arrival in Costa Rica * US to Costa Rica San Jose (SJO) Smaller Flight in Costa Rica * Airline, Flight #, date, and time Smaller Flight, Return to San Jose * Departure date and time Departure to US * (San Jose to Home Airport) How can we make your trip delightful and safe? * not required Any dietary restrictions or preferences? * Mental and Physical Health: Please list any physical disabilities, allergies, conditions, past injuries or any limitations we need to know about. If there are no conditions respond none. * Psychological Conditions: Have you ever been diagnosed with epilepsy, depression, schizophrenia, bi-polar disorder or any other psychological conditions? * If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the medical personnel contacted to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted. * If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the medical personnel in attendance or contacted to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached. * If I should warrant immediate medical attention while on this retreat, I hereby grant permission to the physician selected by Beyond Therapy representatives to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me. * All statements I have made in this document are accurate and correct to the best of my knowledge at the time of submission. I agree to update the staff of Con Smania CR with any additional information pertinent to my attendance at the retreat. * Likeness and Media Release * I agree to Likeness and Media Release, Release of Liability and Assumption of All Risks: I hereby accept any and all risks associated with my refusal to purchase the insurance suggested in the above paragraphs by checking the box below. * Thank you!
