Nourishment: Movement, Meals and Mindfulness Friday, Mar 2 - Sunday, Mar 4, 2012 REGISTRATION Name ____________________________________________________________ Address __________________________________________________________

Email ____________________________________________________________ Phone ____________________________________________________________ Dietary Needs: I do NOT eat chicken fish dairy eggs I AM gluten intolerant dairy intolerant Other food allergies not listed above: __________________________________ Alcoholic Beverages will not be provided for the weekend. If you would like to bring your
own, you are welcome to (a refrigerator is available for storage) and are asked to drink in your room or outside not in the common areas including the dining hall.

Weekend Option: includes two nights accommodations (most with shared bath), five
delicious meals including vegetarian options, 4 Nia classes, an Herb Demonstration with Heather Wetzel, a Food Freedance (a cooking and tasting workshop with Rebecca George), 2 Meditative Morning experiences, Conscious Dance, and time to nourish yourself!

Double occupancy rooming with _____________________________ Double occupancy please match me with a room mate Single occupancy

Saturday Option: Three delicious meals, 2 Nia classes, 1 Meditative Morning experience, a
Food Freedance (a cooking and tasting workshop with Rebecca George), Conscious Dance, and time for nourishing yourself!

Saturday Day Pass please indicate which meals youll be there for B L D Double occupancy Single occupancy Saturday Day Pass $390 $415 $125 $100 deposit to hold space (or total amount) due upon registration: Balance due by Feb 20: Check or money order (written to SusaNia LLC) to: Susan McCulley / SusaNia LLC 809 Locust Avenue Charlottesville VA 22902 Or via PayPal to Susans account: sjmnia@yahoo.com

Nia Retreat at Sevenoaks Retreat Center in Madison, VA With Susan McCulley LIMITATION OF LIABILITY
These paragraphs define our responsibility with respect to my retreats and contracted services. Please read carefully. Your signature below represents acceptance of the following terms and conditions.
I will not hold Sevenoaks Retreat Center and/or Susan McCulley liable for loss or damage to baggage or property or for personal injury or death resulting from acts, omissions, or negligence of any provider of services or accommodations or due to other causes beyond the control of Sevenoaks Retreat Center and/or Susan McCulley, or for loss or additional expenses or inconvenience resulting from acts or omissions of any carrier or any other supplier of services or facilities, or delays, cancellations, re-routings and any other action caused by weather, political disturbances, strikes, lockouts, riots, war, terrorist actions, insurrections or any other reason. Sevenoaks Retreat Center may, in its sole discretion, cancel or change the schedule of all or any part of any program or extension if it considers such action to be in the general interest of participants or their safety, and I waive all claims against Sevenoaks Retreat Center and/or Susan McCulley arising from such actions or decisions. Sevenoaks Retreat Center reserves the right to alter the itinerary when necessary. All prices quoted are valid at the time of publication and every effort is made to honor the original published pricing; extraordinary circumstances may warrant revisions and Sevenoaks Retreat Center reserves the right to revise final pricing when necessary. If it is necessary for Sevenoaks Retreat Center to revise final pricing before the retreat, you will have the option of receiving a full refund if you choose to cancel. I undertake the following obligations. To declare any known illnesses or pre-existing health conditions and to seek medical assurance that it is safe to partake in a retreat of this nature; To sign this legal waiver prior to the commencement of services contracted; To accurately and completely furnish any personal information requested by Sevenoaks Retreat Center and/or Susan McCulley for the purposes of organizing services; To carefully review all information furnished about the retreat; To understand as thoroughly as possible the physical and mental demands of and risks to be encountered during the retreat; To properly equip myself for the retreat; To follow environmental guidelines and regulations while on the trip in accordance with direction from the Sevenoaks Retreat Center guide; To always respect the rights and privacy of other participants. At Sevenoaks Retreat Center's discretion a participant may be asked to leave the retreat or may be disallowed from attending specific segments of the retreat if Sevenoaks Retreat Center deems participation to be potentially detrimental to the group or to the individual participant. Cancellation Policy: For cancellations received by January 15, 2012, we refund all payments. After January 15, 2012, there is no refund for cancellations unless another participant is available to take the spot. It is the responsibility of the cancelling participant to find a replacement for their spot and it is possible that the organizer will be able to assist in this. Photo Release: I understand that photos may be taken at the retreat and that they may be used on Susan McCulleys or other presenters web site/s and in other promotional materials. I hereby give my consent for the use of my photograph and likeness to be used in its publications, including its website. I, the undersigned will not hold Sevenoaks Retreat Center and/or Susan McCulley or their officers or agents responsible for any losses or expenses incurred resulting from cancellation of my trip, accident, sickness, stolen or damaged baggage, any default of a common carrier (airline, train, bus, etc.) whether it be a result of insolvency, bankruptcy, or another financial difficulty, or resulting from any other travel supplier-related problem.

Signature:___________________________________________________ Date: _________________________ Please Print Full Name: __________________________________________________