Presented by Mirian Perez,
Founder & CEO of SHIELD US Co. & Dr. Margaret Gavian CEO of Blue Peak

Reset Button Retreat Application
2023

First name

Last name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Age

Martital Status

Demographics (race, ethnicity, languages?)

If you have any pronoun preferences (she, they, he, etc.) please specify (optional):

In 2-3 sentences, please tell us about yourself:

Why are you interested in attending this retreat?

Why are you signing up for this Reset Button Retreat?

How did you hear about the retreat?

Other things you think are important for us to know?

Agency

Unit/Section

Years of Service

Years total as a first responder (including other agencies)

Military Service? If so, what branch? Combat?

Part of our application process will include a conversation with one of our team members to determine if you are an appropriate fit. Are you willing to meet virtually with a team member?

Participants of Reset Button Retreats must be 18 years of age or older. I am 18 years old or older:

HEALTH RELATED QUESTIONS

Current medical condition being treated:

Previously diagnosed with (medical/mental health dx)

Please tell us more about any of the above:

Currently seeing a Behavioral Health Care provider?

Do you have any physical injuries or limitations that would restrict your ability to engage in retreat activities (swimming, snorkeling, hikes, etc?)

Do you drink?

What is your level of experience with mind-body approaches to health- yoga, meditation, energy work?:

Emergency Contact Information (Contact number/relationship to the party):

RETREAT MODEL & PARTICIPATION GUIDELINES

By submitting this registration form, I am seeking to participate in the Reset Retreat for First Responders. I understand that each retreat has a maximum of fourteen participants. In this retreat, I will be taught an array of strategies to manage stress (such as meditation, guided imagery, biofeedback, working with drawings, breathing, movement). The retreat combines didactic learning, experiential learning, practice and group support. The Reset Retreat is an educational program and this experience is grounded in self-reflection modalities that may bring up strong, transformative emotions within oneself as well as being witness to other’s emotions and experiences within the other participants. We find that sharing and connecting with others creates a wonderful learning environment, helping you become more self-aware and engaged in self-care.

Regular opportunities for sharing are offered in support of building both self-expression and connection with others. Sharing is encouraged yet unforced.

ATTENDANCE

Yes, I am able to make a commitment of punctual attndance to the entirety of the Reset Button Retreat September 15-18th, 2023

EXPERIENTIAL ACTIVITY & ACTIVE PARTICIPATION

Yes, I understand the retreat requires a willingness to engage in educational learning, experiential exercises, and active participation.

EMOTIONS & SHARING

Yes, I understand the retreat requires a willigness to engage in group sharing and listening to others share, and including the processing of emotions.

AWARENESS OF SIGNIFICANT OTHER/PEER IN GROUP

Generally we discourage participating in a retreat with a spouse, family member, or co-worker. It is important to have space to share in an unihibited way and certain relationships may impact your comfort level, even when it appears to be an appealing idea in advance. If you are planning to join the Reset Button Retreat with somone you know, please advise us, and your retreat leaders will explore this further with you in your interview session.

CONFIDENTIALITY

Yes, I understand it is my responsibilty to keep all information shared during the retreat confidential and to demonstrate respect for the other participants at all times. The only exception to this confidentiality rule is if any individual expresses an intent to harm themselves or others. Your group facilitator would be required to take additional action in support of the situation.

VIDEOCONFERENCING

Yes, I understand that an initial get-to-know you session will be held over videocoferencing software. I am willing to do video paticipation and have a device capable of this. Note- the videoconferencing software is free and you will recieve intructions for downloading after completing this registration.

REQUIRED INTERVIEW BEFORE GROUP

Yes, I understand I am required to have a brief interview using the video conferece software with retreat leaders to make sure the program is right for me at this time, and answer any questions. I understand that I am not considered fully registered and will not recieve the instructions for travel, attending the retreat, logistics etc., until I have completed this interview with a retreat leader.

Self-Care

Yes, I understand that participation in this retreat is for self-care and is not an equivalency for medical treatment or professional training.

I agree to all the terms & conditions

FEE/Payment option: Total for 4 day Reset Retreat including transportation NOT including flight is $1,500/person.

Payment Option 1: Pay full price for retreat upfront with discounted rate of $1,300 no later than July 15th, 2023.

Payment Option 2: Pay 1st- half of total price ($750) by June 15th & Final half ($750) by August 15th, 2023.

Financial Feasibility- Do you have the ability to pay for this retreat? Y/N

Please specify which option you choose:

CANCELLATIONS & REFUND POLICY

We expect the demand will, unfortunately, outweigh our ability to provide space for everyone that wants to participate. We kindly request that you email me at Bev@shieldus.app with as much advanced notice of the retreat start date if you are no longer able to attend so that we can offer your spot to another person.

REFUND POLICY

The participant understands that payment for retreat enrollment may be eligible for a partial refund if canceled according to the following terms: (a) if canceled 30 days or more before the beginning of the Reset Retreat, SHIELD US Co. will refund 50% of the payment minus a $50.00 processing fee; and (b) any fees charged for enrollment are non-refundable. Aside from cancelation, the participants enrollment credential is transferable to a future Retreat, or to another Fire or Law Enforcement woman without any fee, provided SHIELD US Co. is notified of the name of the transferee woman in writing no later than 5 days before the Retreat begins. There are no exceptions to these time frames.

ONLINE WAIVER

Any participation in SHIELD US Co. online offerings, trainings and retreats, is entirely voluntary and participant assumes all potential risks. Any experience or services are provided "as is," without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. By purchasing and or enrollment of any offerings the participant acknowledges and agrees to the following:

The participant agrees that the use of all, or part, of the service is entirely at the participant's own risk. Any actions or lack of actions, taken by the participant of such advice is done so solely by choice and responsibility of the participant and is neither the responsibility nor liability of event organizers/facilitators, their agents, employees, officers, volunteers, and/or contractors, and any person or organization associated with them and their activities (collectively known as “SHIELD US Co.” and “Blue Peak”).
The participant understands that any experience, service and/or information at the event is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and the participant will not use it in place of any form of therapy.
The participant recognizes that some group processes provided may require emotional, physical, and mental efforts, and exertion, on the participant's part, which may cause physical, mental or emotional stress. The participant further recognizes that the group processes on the event may require physical exertion, and experimentation on the participant’s part, including by not limited to, violent physical contact and wrestling with other participants, which may cause severe physical, mental, or emotional injury. The participant fully acknowledges and takes full responsibility for all risks involved.
The participant understands that it is his responsibility to consult with his primary health care provider prior to participating and should the participant choose not to consult his health care provider, the participant accepts full responsibility waiving all rights to liability or any claims against SHIELD US Co. & Blue Peach and any of its agents, administrators, or employees.
The participant, and/or legal representatives forever release, waive, discharge and covenant not to sue SHIELD US Co. and Blue Peak and its agents, servants or employees, for any injury, harm or death caused by either negligence or other acts or omissions of the participant, other participants and/or SHIELD US Co./Blue Peak, its agents, servants or employees.
The participant has read and understood this form and all its contents, and the participant voluntarily agrees to the terms and conditions stated above.