Name
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First Name
Last Name
Name you would like on your Nametag
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Email
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Pronouns for your Nametag
Phone
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(###)
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Emergency Contact: Name & Phone Number
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Please share a bit more about yourself & why you are choosing to attend Solsara
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Have you attended a Solsara 3-day Immersion before?
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Yes
No
I've attended a 2-hour intro
If you haven't attended an immersion before, please share who invited you to attend this one for your first time.
Please share your primary motivations for registering for Solsara?
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Have you been addicted to substances or behaviors that have had a negative impact on your life?
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Yes, currently
In the past
No
If you indicated "Yes, currently," please describe.
To better understand and support you, we invite you to share how any significant traumatic experiences you have encountered continue to impact your well-being. These experiences may include, but are not limited to, physical, sexual, verbal, or emotional abuse, neglect, loss, accidents, injuries, illness, violence, natural disasters, near-death experiences, or similar events.
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Please note: While many people who have experienced trauma have successfully attended Solsara and received great benefit, Solsara is not a replacement for therapy. We recommend that people who have experienced significant trauma see a therapist who specializes in trauma before attending Solsara. If you are currently receiving care, please consult with your mental health provider. If you are unsure if Solsara is appropriate for you, please indicate that above and we will contact you to discuss.
Have you ever been diagnosed with, or experienced, mental health conditions such as significant depression or anxiety, Bipolar Disorder, Personality Disorder, PTSD, psychosis, Schizophrenia, etc?
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Yes
No
Other
If you indicated "Yes" or "Other," please describe.
Have you been diagnosed with, or do you consider yourself neurodivergent?
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Yes
No
Other
If you indicated "Yes" or "Other," please describe.
We care about your comfort. Do you have any physical limitations or requests to help you be more comfortable during the weekend? (i.e. sitting in a chair rather than the floor, hearing impairment, mobility, etc)
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Yes
No
If you indicated "Yes," please describe.
Do you have the capacity to host a fellow participant who may be travelling from out of town? If so, please share accomodation details (private room or shared space, size of bed or type of bed, neighborhood, pets, etc). We will share your contact info with participants who are looking for a place to stay.
Do you need a place to stay in Portland in order to attend this immersion? We will share any potential hosts information with you after you have completed your registration.
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Yes
No
COST: We invite you to contribute an amount that feels comfortably generous for your life circumstances and matches the value you receive from this offering.
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Tier 1 - Supporting $795 You might choose this tier if you: - Own property or other significant assets - Make over $100K per year - Travel for leisure Tier 2 - Sustaining $595 You might choose this tier if you: - Can go out to eat without thinking about your finances - Pay full price for other healing modalities such as massage, acupuncture, coaching, other workshops, etc - Have a salaried job with benefits - Have family that would financially support you if you needed it Tier 3 - Supported $395 You might choose this tier if you: - Do not have a financial safety net - Have large debt or student loans - Have to save up to attend a weekend event like this Tier 4 - Scholarship $195 (Requires Application, received in response to this form) Limited scholarships are available for each event You may consider this option if you: - Are unemployed or unable to work - Struggle to pay for your basic needs (food, home) - You live below the poverty line - Please get in touch with us if you have questions about tuition.
I have read, and agree to, the following Wellness Guidelines. If you have any symptoms before the event, please do not attend. This includes coughing, sneezing, running nose, sore throat, fever, unusual fatigue, body aches, diarrhea, nausea, vomiting, or any other possibly contagious symptoms. We will refund your registration minus a $20 processing fee to cover some associated costs. If you develop any symptoms during the weekend, please talk to us immediately. We may ask you to mask, test, stay home, or any combination of the above. Thank you for being willing to take care of our collective health!
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I have read, and agree to, the Solsara Cancellation Policy. If you need to cancel your registration 30 days or more before the start of the Immersion, you will receive a full refund minus a $20 processing fee. For cancellations made 15-29 days before the start of the Immersion, half of your payment will be refunded. If you cancel within 15 days of the Immersion's start date, or do not show up, no refunds will be available (with the exception of the wellness guidelines). It is required that you attend the first morning of the first day or you will forfeit your attendance for the weekend. Exceptions will be considered on a case by case basis for emergencies only.
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I am able to attend all days and all hours of the Immersion.
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I have read, and agree to, the Solsara Terms and Conditions In consideration of my participation in the Solsara Immersion, I hereby generally release Larry Kaplowitz, Sara Eden Gally, Carrie Farrell, Solsara assistants, and the host venue, from any liability whatsoever related to my participation in the Solsara Immersion. This waiver and release shall be binding on my heirs and assigns and shall be in favor of Solsara, all promoters, employees, agents, the host venue, other participants or any individuals or entities in any way connected to the Solsara Immersion from any liability whatsoever in the event that I sustain any physical injury or mental damage as a result of my decision to participate in any activities of the Solsara Immersion.
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I acknowledge and understand that, while some Solsara facilitators are licensed mental health counselors, they are providing this workshop solely for educational and personal development purposes. I further understand that participation in a Solsara workshop does not establish a therapeutic relationship or substitute for professional mental health services.
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