Please complete this form in its entirety. All information is confidential. Thank you. 

Name *
Mailing Address *
Mailing Address
Cell Phone *
Cell Phone
Date of Birth *
Date of Birth
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you are not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
Please note: If you have answered “yes” to one or more of the above, please consult your physician before engaging in physical activity. Tell your physician know which question you answered “yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Please write your name in full as confirmation that you have read and that you understand the above.
Do you sit for extended periods during the day? *
Do you wear high heels? *
Does your job cause you anxiety or stress? *
Please list cardiovascular issues, diabetes, cancer, or other medical issues.
Do you experience any chronic pain or have you ever sustained an injury (knee, back, ankles, etc)? *
Have you had surgery? *
Do you have any food allergies or intolerances? *
Do you follow a special diet? (i.e. vegetarian, vegan, pescatarian) *
Would you like us to book you a massage? *
You have the option to purchase a 60 minute massage for $120. We will schedule the massage for you to occur over the course of the weekend. All payments will be made directly to the provider. Massages will take place at the retreat location.

By submitting this form, you understand and agree to the following:

Allison Kalsched,  Allyson Cherins, and Meemur, LLC  strongly recommend that you consult with your physician before beginning any exercise program.

You should be in good physical condition and be able to participate in the exercise.

Allison Kalsched is not a licensed medical care provider and represents that it has no expertise in diagnosing, examining, or treating medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition.

You should understand that when participating in any exercise or exercise program, there is the possibility of physical injury. If you engage in this exercise or exercise program, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Allison Kalsched, Allyson Cherins and Meemur, LLC from any and all claims or causes of action, known or unknown, arising out of Allison Kalsched’s, Allyson Cherin’s or Meemur LLC’s  negligence.

Please be aware of the cancellation policy for NOURISH.