2022 #25 Texas Fall Encounter

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Name* This field is required.
First Name
Last Name
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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
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Phone Number* This field is required.
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Address* This field is required.
Street Address
Street Address Line 2
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Please Select
United States
Afghanistan
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The Bahamas
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Cambodia
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Cape Verde
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Chad
Chile
China
Christmas Island
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Cote d'Ivoire
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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
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Jamaica
Japan
Jersey
Jordan
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North Korea
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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
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Date of Birth* This field is required.
Date
Month
Day
Year
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Roommate RequestIf you would like to request to stay in a room with someone else on the trip, please specify their name here.
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Emergency Contact Name* This field is required.
First Name
Last Name
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Emergency Contact Relationship to Participant* This field is required.
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Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
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Family Doctor Name* This field is required.
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Family Doctor Phone Number* This field is required.
Area Code
Phone Number
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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
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Health Insurance Company Name* This field is required.
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Health Insurance Policy Number* This field is required.
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Health Insurance Phone Number* This field is required.
Area Code
Phone Number
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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
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Known Allergies* This field is required.Specify any allergies/drugs you are allergic to
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Food Allergies and Restrictions* This field is required.Specify any food allergies (soy, nut, gluten, celiac, etc.) you might have.
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IRON HORSE RANCH - WAIVER OF LIABILITY* This field is required.I ACKNOWLEDGE THAT BY SIGNING THIS DOCUMENT, I AM ASSUMING RISKS, AND AGREEING TO INDEMNIFY, NOT TO SUE AND RELEASE FROM LIABILITY MOODY NATIONAL IRON HORSE RANCH, LLC, MOODY NATIONAL TRAINING CENTER, LLC, MOODY NATIONAL REALTY COMPANY, L.P., MOODY NATIONAL MANAGEMENT, L.P., MOODY SECURITIES, LLC, THE ORGANIZER OF ANY EVENT LOCATED AT THE IRON HORSE RANCH LOCATED IN BURLESON COUNTY, TEXAS (THE “RANCH”) AND THEIR RESPECTIVE AFFILIATES, CORPORATE PARENTS, MEMBERS, PARTNERS, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS (COLLECTIVELY “RELEASEES”), AND THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS. THIS RELEASE IS A CONTRACT WITH LEGAL AND BINDING CONSEQUENCES AND IT APPLIES TO ALL RISKS ASSOCIATED WITH ENTERING THE RANCH PREMISES AND ANY RANCH ACTIVITIES. In consideration of the issuance of a license to me by one or more Releasees to enter the Ranch premises, I hereby freely agree to and make the following contractual representations and agreements: I ACKNOWLEDGE THAT PARTICIPATING IN ACTIVITIES AVAILABLE AT THE RANCH, AND THE RANCH PREMISES IN AND OF ITSELF, CONTAIN INHERENTLY DANGEROUS RISKS, AND I FULLY ASSUME THE RISKS ASSOCIATED WITH THE SAME, by way of example, and not limited to: dangers associated with shooting sports, water activities including swimming, hunting, fishing, horseback riding, riding motorized vehicles, the dangers arising from surface hazards, THE RELEASEES’ OWN NEGLIGENCE and the negligence of others. I acknowledge that Releasees do not provide lifeguards for water activities and engaging in those water activities is at my own risk. For myself, my heirs, executors, administrators, legal representatives, assignees, and successors in interest (collectively “Successors”) I HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS, AND PROMISE TO INDEMNIFY AND NOT TO SUE THE RELEASEES FROM ANY AND ALL RIGHTS AND CLAIMS INCLUDING CLAIMS ARISING FROM THE RELEASEES’ OWN NEGLIGENCE, which I have or which may hereafter accrue to me and from any and all damages which may be sustained by me directly or indirectly in connection with, or arising out of, my entering the Ranch premises or participation in Ranch activities. I agree, for myself and my Successors, that the above representations are contractually binding, and are not mere recitals, and that should I or my successors assert a claim contrary to what I have agreed to in subsequent waiver or modification. I consent to the release by any third party to Releasees and their insurance carriers of my name and medical information that may relate solely to any injury or death I may suffer arising from my activities at the Ranch. Every term and provision of this contract is intended to be severable. If any one or more of them is found to be unenforceable or invalid, that shall not affect the other terms and provisions, which shall remain binding and enforceable. I HAVE READ THIS RELEASE CAREFULLY BEFORE SIGNING, AND I UNDERSTAND WHAT IT MEANS AND WHAT I AM AGREEING TO BY SIGNING.
Yes
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IRON HORSE RANCH - PERSONAL PROPERTY USAGE AGREEMENT* This field is required.This Agreement is between MOODY NATIONAL IRON HORSE RANCH, LLC (the “Ranch”) and the Guest. Guest acknowledges that Guest has read, is aware of, and accepts full responsibility for and is bound by the terms and conditions contained in this Agreement. General Terms Regarding Usage of Ranch Property. Damage to Ranch Property. Except to the extent restricted, modified or limited by State law, Guest accepts responsibility for damage caused by Guest or Guest’s Children to Ranch property. Guest shall pay Ranch the amount necessary to repair or replace the damaged Ranch property, whichever is less. Personal Property. Ranch is not responsible for any damage to, loss or theft of, any personal property or data contained therein, while Guest or Guest’s Children are on Ranch property regardless of fault or negligence of Ranch. Supplemental Vehicle Usage Terms. Definition. A “Vehicle” is any motorized equipment owned by the Ranch and utilized by the Guest, including, but not limited to, jet skis and rangers. Limits on Use. Guest agrees to the following limits on use: - Vehicle shall not be driven by any person impaired or under the influence by the use of narcotics, alcohol, intoxicants, or drugs, used with or without a prescription. - Vehicle shall not be operated by anyone: who has given a fictitious name, false address, does not possess a driver’s license, or who possesses a false or invalid driver’s license. Notice Requirement. Damage to Vehicle must be immediately reported in writing to management, and in no event later than before Guest leaves the Ranch. Damage to Vehicles. Except to the extent restricted, modified or limited by State law, Guest accepts responsibility for damage to Vehicle regardless of fault or negligence of Guest, or Guest’s Children, or any other person or act of God. Guest shall pay Ranch the amount necessary to repair Vehicle. If the Ranch determines Vehicle is salvage, Guest shall pay Ranch the fair market value of the Vehicle. For purposes of this Agreement, fair market value shall be the retail value of Vehicle immediately preceding the loss. Indemnity. Guest shall defend, indemnify and hold Ranch or its affiliate(s) harmless from all losses, liabilities, damages, injuries, claims, demands, costs, attorney fees and other expenses incurred by Ranch and/or its affiliate(s) in any manner from the use of Vehicle by Guest or Guest’s Children, including claims of, or liabilities to, third parties. General Terms Severability. If any provision of this Agreement is determined to be unlawful, contrary to public policy, void or unenforceable, all remaining provisions shall continue in full force and effect. Headings. The headings of the numbered paragraphs of this Agreement are for convenience only, are not part of this Agreement and do not in any way limit, modify or amplify the terms and conditions of this Agreement. Choice of Law. All terms and conditions of this Agreement shall be interpreted, construed and enforced pursuant to the law of the State of Texas. Attorney’s Fees. The prevailing party in any legal proceeding brought under or with respect to this Agreement is entitled to recover from the non-prevailing party all costs of such proceeding and reasonable attorney’s fees. AGREED TO: The undersigned warrants that he/she is of legal age, is legally competent to execute this agreement, and that he/she does so of his/her own free will and accord without reliance on any representation of any kind or character not expressly set forth herein.
Yes
21
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
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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 or Encounter, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Iron Horse Ranch or Adventures of the Heart liable for any illness or injury.
Yes
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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 swimming, volleyball, zip lining, gun shooting, hiking and golf 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
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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
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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
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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
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