2021 #24 Georgia Fall Encounter

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.If you have attended a past event, please use the same email to properly link your profile information.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Roommate RequestIf you would like to request to stay in a room with someone else on the trip, please specify their name here.
7
Emergency Contact Name* This field is required.
First Name
Last Name
8
Emergency Contact Relationship to Participant* This field is required.
9
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
10
Family Doctor Name* This field is required.
11
Family Doctor Phone Number* This field is required.
Area Code
Phone Number
12
Family Doctor Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Health Insurance Company Name* This field is required.
14
Health Insurance Policy Number* This field is required.
15
Health Insurance Phone Number* This field is required.
Area Code
Phone Number
16
Health Insurance Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Known Allergies* This field is required.Specify any allergies/drugs you are allergic to
18
Electronic Signature Consent* This field is required.By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Yes
19
Agree Not Psychotherapy* This field is required.I hereby voluntarily consent to participate in this event. I understand this event is educational and not psychotherapy or a substitute for psychotherapy.
Yes
20
Agree to COVID Risk* This field is required.By clicking submit below, you are acknowledging that an inherent risk of exposure to COVID-19 exists in any public place where people are present. By attending the Adventures of the Heart Expedition, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Cohutta Springs or Adventures of the Heart liable for any illness or injury.
Yes
21
Agree to Activities* This field is required.I understand that the event and its various parts involve mental, intellectual, emotional and physical activity, including, but not limited to: role playing, and exercises that may tax my intellectual, mental, and emotional capacity. I understand that the event and the optional free time activities of paintball, rock climbing, hiking and rappelling may pose a risk of physical or other injury to myself and others. I understand and acknowledge that my participation in the event and the optional free time activities and in every separate part thereof is purely voluntary and that at all times I will be free to choose NOT to participate in any part or all of the event. I acknowledge my responsibility for exercising my own judgment and initiative in choosing what parts of the event, if any, I will participate in. I acknowledge that my choices and actions pose a risk of physical or other injury to myself or others. By this consent I knowingly and voluntarily assume the risk of any physical or other injury either to myself or caused to others by me in the event. I hereby release Adventures of the Heart its officers, directors, employees, agents and staff from any and all liability for physical and other injuries to myself. I hereby agree to indemnify and hold harmless Adventures of the Heart, its officers, directors, employees, and staff from any and all liability for physical and other injuries to myself and for any injury to others caused by me.
Yes
22
Assumption of Risk* This field is required.I take responsibility for consulting with a medical doctor and/or psychotherapist prior to participating in the event concerning any known or potential physical, mental or emotional condition which I have or may have, for the purpose of getting medical and/or psychotherapeutic permission to participate. I assume the risk, by this consent, of any physical or other injury, illness or conditions during the event and hereby release Adventures of the Heart its officers, directors, employees, agents, and staff from any and all liability thereof.
Yes
23
Authorization to Help* This field is required.4) I hereby authorize Adventures of the Heart, its officers, directors, employees, agents and staff to take any and all reasonable steps on my behalf in the case of any physical or other injury, illness or condition I might suffer during the event. Adventures of the Heart, its officers, directors, employees, agents and staff may apply emergency first aid, engage physicians of any kind, nursing services, ambulance services, paramedic services, or any other service or personnel that in the sole discretion of Adventures of the Heart, its officers, directors, employees, agents or staff may be deemed reasonable or necessary. I hereby agree to indemnify and hold harmless Adventures of the Heart, its officers, directors, employees, agents and staff of and from any and all liability, claims, suits and damages, including, but without limitation, the cost, arising out of or with respect to the engagement of such services and/or personnel on my behalf. Further, I hereby knowingly and voluntarily release Adventures of the Heart, its officers, directors, employees, agents and staff of and from any liability for any physical or other injury that I may suffer as a result of Adventures of the Heart engagement of such services and/or personnel on my behalf.
Yes
24
Assumption of Risk / Waiver of Liability* This field is required.It is my desire to participate in the outdoor recreational activities provided by COHUTTA SPRINGS CONFERENCE CENTER. Everything reasonable has been done to assure that activities have been made as safe as possible; however, I, the undersigned, am fully aware of the risks associated with all outdoor recreational activities, which would include, but are not limited to, water activities, horseback riding, caving, climbing/rappelling, guided hikes, canoeing/rafting, and participating in the challenge/ropes course. I, the undersigned, am fully aware that it is possible for me to receive injuries to my body which could be permanently disabling or could even cause me to die. As for consideration to participate in these activities, I, the undersigned, hereby knowingly and intelligently assume the risks of harm and/or bodily injury to my person or property that are associated with or arise out of the activity. I, the undersigned, agree to not knowingly place myself or other persons in hazardous situations. I, the undersigned, also promise to abide by the rules, which are designed for my safety and agree to use all appropriate equipment (such as life vests, helmets, etc.) as specified by CSCC. I, the undersigned, realize that outdoor activities have inherent risks. I, the undersigned, knowingly accept and assume this risk, and agree to release CSCC and its parent organizations from any and all liability and responsibility. Further, I agree to indemnify and hold harmless said organizations from any and all claims, damages, injuries, and expenses arising out of or resulting from my participation in the outdoor activities. I further agree to release, acquit, and covenant not to sue said organizations for any and all actions, causes of action, claims or damages, damages in law, or remedies in equity of whatever kind, including the negligence of said organizations. I understand “said organizations” includes their agents and employees. I, the undersigned, am 18 years of age, or older, and have read and understood this entire agreement.
Yes
25
Final Acknowledgement* This field is required.By entering my name below, I am aware in signing this document for participation in this program that certain elements of the activity are physically and emotionally demanding. Furthermore, I understand that certain risks and dangers exist in the activities in which I am participating.
First Name
Last Name
26
Get Page URL
Should be Empty: