In order to join the waitlist for the Writing as a Pathway at Commonweal retreat, please complete the form below. If you have trouble with this form or have additional questions, you can contact Laura by email at firstname.lastname@example.org or on 1-800-611-5144 (toll free in the US and Canada). Commonweal Waitlist Form Because the retreat is just around the corner, we’ll need to process any last minute cancellations and fill those spots from the waitlist as fast as possible. Please fill out the following questions as thoroughly as possible:This personal information is only for the confidential use of your facilitators. Although this is a writing retreat and not therapy, writing practice can bring up strong emotions, unearth memories from the past, and bring you face to face with whatever issues are unresolved in your life. If you are currently under the care of a therapist or psychiatrist, or have any questions about whether you should participate in this retreat, please consult your physician or therapist, as well as the facilitators, before attending the retreat. Personal InformationFirst Name*Last Name*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Cell PhoneBest Time to Call YouWhat name would you like on your nametag?Birthday (month/day/year)GenderOccupationPlease answer the following:How did you learn about this workshop? (Be as specific as possible)*What are your housing preferences? Do you prefer a single or a double? Are you open to taking the first available spot, whatever it might be?Do you have any special dietary needs?Are you interested in obtaining CEUs (a small fee will be added to your final payment)?* Yes, I would like to earn CEUs. No, I am not interested in CEUs. If yes, please list your credential, your license number and the expiration date.Would you like to be added to Laura's email list?* Yes! Sign me up to hear more from Laura about her travels, receive writing prompts, and learn about upcoming retreats and workshops. No. Please do not add me to Laura's email list. I’m already on Laura’s mailing list and love her weekly writing prompts! Travel DetailsHow will you be traveling to the retreat? If you’re driving, are you interested in carpooling?If you’re flying, would you like to work with our travel agent? (She can ensure that you arrive and depart at the proper times so you can fully participate in the whole retreat.)*Travel Insurance*We strongly recommend travel insurance if you have any concerns about the possibility of having to cancel your participation in this retreat. Travel insurance can protect your investment in this retreat regardless of whether you drive or fly. And our travel agent can arrange it for you whether or not you use her to set up your travel. NOTE: If you have pre-existing conditions, travel insurance must be purchased within 3 weeks of paying your deposit). Would you like to be contacted about travel insurance? Yes. I would like your travel agent to contact me about travel insurance for this retreat.I will purchase my own travel insurance.I decline travel insurance and take full responsibility for all losses should I have to cancel.Learning More About You and Your Reasons for AttendingWhat are your reasons for attending this retreat? Please be as specific as possible.*How have you worked with these issues and this material in the past?*What do you hope to gain from attending this retreat?*On the following scale, check where you are now on the continuum of healing around your issues of grief, loss, and uncertainty.* 10 - I feel strong, positive and empowered. 9 8 7 6 5 - OK, but life is kind of flat and neutral. "I'm just getting by." 4 3 2 1 - Can't get out of bed, despairing & hopeless. Using the same scale, how would you describe the range from the worst you've felt to the best you've felt over the course of the past six months? ("I'm a 3-7." "I've been a 6 to a 10.")List all of the medications you're taking (for sleep, medical conditions, depression, anxiety, etc.). Include the name of the drug and why you are taking it.Physician's Name, Phone, and State:Are you currently in therapy or any group support? If yes, details please.*If you are currently under the care of a therapist or counselor, their name, phone, and state:Have you ever been hospitalized for medical or psychiatric reasons? If yes, details please.*Have you attempted or seriously considered suicide? If yes, details please.*Do you have any other special needs or concerns that might influence your participation in the retreat?Is there anything else about you that we should know?Emergency Contact NameYour Relationship to Your Emergency ContactEmergency Contact's PhoneEmergency Contact's Email Release*I hereby confirm that I have read and understood the above information and have answered all questions completely and honestly and have not withheld any information. My general health, other than as noted, is good. I have included all physical and psychological factors that may affect my participation on this retreat. I realize that failure to disclose such information could result in serious harm to myself and/or fellow participants. I agree to indemnify and hold Laura Davis & The Writer's Journey LLC, harmless if all relevant information is not disclosed, and to notify them should there be any change in my health or psychological status prior to the start of my retreat. I agree not use alcohol or recreational drugs during the retreat and understand that this workshop may bring up strong emotions or challenging psychological issues. I agree to hold the Writer’s Journey LLC, teachings, Laura Davis, and their agents harmless against all loss, damage, liability, or expense arising out of, or in connection with anything owned or controlled by this retreat conducted by The Writer’s Journey, LLC, or including any loss resulting from any acts, failure to act, or negligence of The Writer’s Journey, LLC, Laura Davis, or their agents. I agree that my use of the premises, facilities and equipment of Commonweal Retreat Center is undertaken by me at my own risk, and that Commonweal, The Writer’s Journey, LLC, and their employees are absolved and discharged from all liability for any loss or damage I may incur of my personal property. I agree.No, I do not agree.EmailThis field is for validation purposes and should be left unchanged.