Women’s Wellness Retreat

Health Information & Liability Waiver Form

Breeze Sports Therapy Reviva Retreat

Dates: 8/05/2026 -10/05/2026

Location: Newhouse Farm Cotages, Tiverton, Devon

This form must be completed by all participants before attending the retreat.

MEDICAL HISTORY

Please provide details of any current or past medical conditions that we should be aware of to support your safety and wellbeing during the retreat.

Examples may include (but are not limited to):

• Heart conditions

• Respiratory conditions (e.g., asthma)

• Diabetes

• High or low blood pressure

• Chronic pain conditions

• Mental health considerations

• Recent illness

• Surgery recovery

MEDICATIONS

Please list all medications you are currently taking (including prescription and regular over-the-counter medications).

ALLERGIES

Please list any allergies you have (including food, medication, environmental or skin sensitivities).

PHYSICAL LIMITATIONS & INJURIES

Please tell us about any injuries, joint issues, muscular conditions, or mobility limitations that could affect your ability to participate in physical activities such as:

• Yoga

• Resistance Training

• Walking or hiking

• Stretching or mobility exercises

• Breathwork or movement practices

• Group wellness workshops

• Mindfulness or personal development sessions

  
  

HEALTH SCREENING (PAR-Q)

Please answer YES or NO to the following questions.

You may be asked to provide medical clearance from a healthcare professional before participating in certain activities.

Please indicate if you currently have or have previously experienced any of the following:

Do you require activity modifications or additional support?

Participants are encouraged to:

• Work at their own pace

• Stop if they feel pain, dizziness, or discomfort

• Inform facilitators of any concerns immediately

Assumption of Risk

I acknowledge that participation in retreat activities involves inherent risks, including but not limited to:

• Physical injury

• Muscle strain or soreness

• Slips, trips, or falls

• Aggravation of pre-existing conditions

I understand that I am voluntarily participating and assume full responsibility for my health and wellbeing during the retreat.

Medical Responsibility

I confirm that:

• I am physically capable of participating in retreat activities.

• I will inform facilitators if my health status changes during the retreat.

• I will stop participation if I experience pain, discomfort, dizziness, or illness.

The retreat organisers do not provide medical treatment and are not responsible for diagnosing or treating medical conditions.

Liability Waiver

To the fullest extent permitted by law, I agree to release and hold harmless the retreat organisers, facilitators, venue staff, and partners from any liability for:

• Personal injury

• Illness

• Loss or damage to personal property

• Any incident occurring during or related to participation in retreat activities

This waiver applies except where liability cannot be excluded under applicable law.

Consent for Participation

By signing below, I confirm that:

• The information provided in this form is true and accurate.

• I have read and understood this PAR-Q and liability waiver.

• I agree to participate voluntarily in retreat activities.

Optional Photo & Media Consent

During the retreat, photographs or videos may be taken for promotional purposes.