First Name
Last Name:
Email
Phone:
Address - street and no.:
Suburb
Postcode ________________________________________________________________________________________________________ Date of Birth
Emergency Contact Name:
Emergency Contact Phone:
Are you an ordained sangha member? noyes
Have you previously done a Nyung Nä? noyes
Have you previously attended any retreat? noyes ________________________________________________________________________________________________________ Do you have medical or health issues that will affect your participation in a Nyung Nä? Which, in particular, would be aggravated by physical exertion, fasting or dehydration?
Cardiovascular disease in general, eg cardiac failure, moderate to severe hypertension, ischemic heart disease (angina): noyes ______________________________ Diabetes: noyes ______________________________ Epilepsy: noyes ______________________________ Renal Impairment: (kidney disease) noyes ______________________________ Any other health issues you think we should be aware of: _______________________________________________ What medications do you take?
Because retreats can sometime be quite disturbing, we need to know if you have or have had any mental health issues? Please be specific. ________________________________________________________________________________________________________ RELEASE AND WAIVER OF LIABILITY: __________________________________________ 1. I am, or will be participating in the Nyung Nä offered by Atisha Centre, during which I will be eating only one meal on the first day and no fluids or food from that midnight until 6:00am on the third morning. I understand that the Nyung Nä involves many prostrations over the two and a half days. I recognise that such fasting and abstinence from fluids, physical activity and exertion may be difficult and may cause or aggravate a physical injury or medical condition. I am fully aware of, and accept the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participating in the Nyung Nä, and to receive prior approval to participate. I represent and warrant that I am physically fit and I have no medical condition or injury which would prevent my full participation in the Nyung Nä. 3. In consideration of being permitted to participate in the Nyung Nä, I agree to assume all full responsibility for any risks, conditions, injuries or damages, known or unknown, which I might incur or aggravate as a result of my participating in same. 4. In further consideration of being permitted to participate in the Nyung Nä, I knowingly, voluntarily and expressly waive any claim I may have or acquire against Atisha Centre or the FPMT for any injury, condition or damages that I may sustain as a result of entering or being on the premises or participating in the Nyung Nä sessions. 5. I accept that Atisha Centre will call an ambulance should it be deemed I need medical attention and I accept that I shall be liable for any expenses incurred. 6. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Atisha Centre or FPMT, for any injury, condition, or death which arises, is caused by or is aggravated by reason of my participation in the Nyung Nä. 7. I understand that it is my continuing responsibility to inform the Programme Coordinator and Leader of the Nyung Nä of any previous medical conditions, injuries or surgeries prior to my first session and at such other times as I acquire information as to same. 8. I also understand that, except for a monetary refund, I have no claims against Atisha Centre or FPMT (except for monetary refund) by reason of their refusal to allow me to participate in the Nyung Nä. ________________________________________________________________________________________________________ By clicking the SUBMIT button below, you assert that you have read the above Release and Waiver of Liability and fully understand its contents. You voluntarily agree to the terms and conditions stated above.
