Elemental Alchemy Retreat Registration Form - Empowering Wellness with Leona Douglass

(No payment) Elemental Alchemy Retreat Registration Form

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Do you have any health concerns or mobility limitations we should be aware of?

Do you have any allergies or dietary restrictions? (Cacao is prepared with coconut milk)

Emergency Contact Info

First Name

Last Name

Phone/Mobile

Relationship to You

Non-refundable

I understand that my retreat fee is non-refundable but transferable.

Confirmation of spot

I understand that my spot is not confirmed until my first payment is received.

Confirmation of limited lodging

I understand that additional lodging is limited and available only when confirmed.

Confirmation of payment arrangements.

I understand that payment plans must be arranged directly before registration is completed.

Confirmation of VIP/private session scheduling.

I understand that VIP sessions and private sessions are scheduled based on availability and may occur onsite, pre- retreat, or post-retreat depending on the session type.

Participant Waiver, Release of Liability + Responsibility Agreement

I voluntarily agree to participate in Elemental Alchemy: Rise Rooted, Flow Free, hosted by Empowering Wellness, Leona Douglass, Lightness1All, LLC, and Rev. Dr. Ellen L. Mosti at Lightness1All Retreat Oasis in Venice, Florida.

I understand that this retreat may include yoga, breathwork, meditation, sound healing, cacao ceremony, ecstatic dance, massage/bodywork, energy healing, creative activities, outdoor activities, pool time, kayaking or waterfront activities, fire ceremony, meals, lodging, and other retreat experiences. I understand that participation in any physical, emotional, spiritual, energetic, water-based, outdoor, or movement-based activity carries some risk, including but not limited to physical injury, emotional discomfort, allergic reaction, illness, slips, falls, water-related risks, heat exposure, insect bites, property loss, or other known or unknown risks.

I accept full responsibility for my own health, safety, choices, belongings, and participation. I agree to participate only in activities that feel safe and appropriate for my body, health, mobility, emotional state, and personal well-being. I understand that I may pause, modify, or decline any activity at any time.

Draft for Legal Review - Elemental Alchemy Retreat Registration + Waiver

I confirm that I have disclosed any relevant health concerns, mobility limitations, allergies, dietary restrictions, medical conditions, medications, or other information that may affect my participation. I understand that cacao may be prepared with coconut milk and that meals may be prepared in a kitchen where common allergens may be present.

I understand that Empowering Wellness, Leona Douglass, Lightness1All, LLC, Rev. Dr. Ellen L. Mosti, their assistants, contractors, practitioners, volunteers, affiliates, and representatives are not diagnosing, prescribing, treating, or providing medical care, mental health therapy, or medical advice. I agree to consult with my physician, licensed healthcare provider, or mental health professional as needed before participating in retreat activities, especially if I have any medical condition, injury, pregnancy, cardiac history, mobility limitation, allergy, or other health concern.

In consideration of being permitted to participate in this retreat, I knowingly and voluntarily release, waive, discharge, and hold harmless Empowering Wellness, Leona Douglass, Lightness1All, LLC, Rev. Dr. Ellen L. Mosti, the property owner, assistants, contractors, practitioners, volunteers, affiliates, and representatives from any and all claims, liabilities, losses, injuries, damages, costs, or expenses that may arise from my participation in the retreat, my use of the property, my use of the pool, dock, outdoor areas, lodging spaces, or any retreat-related activity, except where prohibited by law.

I understand that I am responsible for the security of my personal belongings and valuables. I agree not to hold Empowering Wellness, Lightness1All, LLC, Leona Douglass, Rev. Dr. Ellen L. Mosti, or any affiliated parties responsible for lost, stolen, or damaged personal property.

I understand that this retreat is held in a private villa and agree to respect all house rules, private areas, parking instructions, safety guidelines, quiet hours, and boundaries communicated before or during the retreat.

I have read this waiver and release of liability, understand its contents, and voluntarily agree to its terms.

Photo/Video Release

I give permission for photos or videos of me taken during the retreat to be used by Empowering Wellness and Lightness1All, LLC for marketing, social media, website, email, and promotional purposes.

I do not give permission for my image or likeness to be used in marketing or promotional materials.

Participant Acknowledgment + Signature

By signing below, I acknowledge that I have read, understand, and voluntarily agree to the terms of this registration form, payment terms, participant waiver, release of liability, and photo/video selection.

First Name

Last Name