Physical Examination and Clinical Skills 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)

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 ?

How would you describe your current knowledge/ skills with hands-on assessment?(Required)

No prior skills or knowledge

Beginner - some theoretical/ practical skills, but lacking confidence

Intermediate - comfortable and confident but needing practice

Advanced - practicing these skills regularly with patients

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?

Do you conduct any physical assessments on your patients?(Required)

Yes

If yes, which ones?

Do you have any of the following physical assessment equipment?

Stethoscope

Sphygmomanometer

Ophthalmoscope

Otoscope

Reflex hammer

Tuning fork

Thermometer

If yes, please bring them to class.

Other equipment?

If yes, please bring them to class.

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

Bring a notebook, pens, flashlight, penlight, your favorite anatomy / physiology / pathology / clinical skills textbooks.

Participants are recommended to review content on clinical examination in advance of the intensive. A very useful site is University of California San Diego's Practical Guide to Clinical Medicine online.

Fees for 6 day intensive

$600 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, Katolen Yardley and Chanchal Cabrera, nor the location (Innisfree Farm) can or will be held liable or responsible for how the student uses and applies the knowledge gained in this program.

3. Students understand and agree that in order to learn and practice physical assessment skills it is necessary to practice on each other. This will require partial disrobing. Students are asked to wear loose clothing that can be removed with shorts and a T shirt underneath.

4. 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) and the above cancellation clause 4.(Required)

I Agree

Physical Examinations and Clinical Skills Herb Camp: Application Form and Waiver