Clinical Phytotherapy Case Studies Herb Camp: Application Form and Waiver

Part 1: Contact Info

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Emergency contact: Name and Phone Number(Required)

Part 2: Prior Clinical Experience/ Training

Are you currently enrolled in a herbal medicine training program?(Required)

Yes

If yes, which one and how many hours have you completed ?

Have you observed patient intakes in a herbal medicine clinic?(Required)

Yes

Have you conducted patient intakes in a herbal medicine clinic?(Required)

Yes

Are you currently operating a private practice and seeing clients?(Required)

Yes

If yes, how many years in practice?

Are you currently working in health care in some capacity, or have you in the past?(Required)

Yes

If yes, how many years in practice?

If yes, in what capacity or role?

Part 3: Food and accommodation

Registration fees include use of the herbal tea bar and a vegetarian lunch each day. Camping is available on site for a fee $35 per person per night including breakfast.

For campers – please note:

Campers are required to supply their own tent, mattress and bedding. There are toilets and a hot shower on site.

There are very limited cooking facilities for campers and evening meals are not provided.

The property is close to Cumberland (10 minutes) or Courtenay (15 minutes) for various stores and restaurants.

No camp stoves or fires allowed (extreme fire hazard).

I would like to camp.(Required)

Yes

(Once you’ve completed this form, please purchase camping here).

For non-campers:

There are numerous AirBnB or VRBO properties within a few minutes of the gardens. Look for Royston, Cumberland or south Courtenay as a location guide.

Dietary Restrictions

Gluten free

Dairy free

Other serious food allergies?

Medical Conditions: Do you have any serious/ life-threatening medical conditions (e.g. allergies, seizures, asthma etc)? If yes, please list below.

Preparation

Once you have been accepted into the program we will send you a template for submitting a case review for consideration, at least two (2) weeks prior to the start of the program.

Fees for 5 day intensive

$650 plus GST (includes lunch each day). Includes a $150 non-refundable deposit.

Camping on site: $35 per person per night (includes breakfast). Purchased separately.

All fees plus GST@ 5%

Cancellation Policy:

Should you need to withdraw for any reason, we ask that you provide at least two weeks notice, prior to the workshop start date, for a full refund (minus the non-refundable deposit).

Cancellation with less than 2 weeks notice will lead to forfeiture of all fees.

Waiver and disclaimer

1. Students understand and agree that nothing taught in this program gives them permission or license to practice medicine. Material is presented for educational purposes only.

2. Students understand and agree that neither the instructors, David Winston and Chanchal Cabrera, nor the location (Innisfree Fam) can or will be held liable or responsible for how the student uses and applies the knowledge gained in this program.

3. Cancellation with less than 2 weeks notice will lead to forfeiture of all fees.

By checking the I agree box below I, the registrant, confirm and assert that I agree to the above waiver clauses 1, 2 and 3 as above(Required)

I Agree

Name

This field is for validation purposes and should be left unchanged.