Adult Camping Registration Form

Courageous Moms Retreat '2022 Registration Form

NO EXPERTS, JUST MOMS: UNPLUGING, RELAXING, RECONNECTING
Courageous Mom Information
Name *

First Name Last Name
Address *

Street Address

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City State / Province

Postal / Zip Code Country
E-mail *
Cell Number *

Area Code Phone Number
Shirt size *
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship
Phone Number *

Area Code Phone Number
Drug Allergies or Other Allergic Reactions:
Dietary Needs/Restrictions:
Retreat Information
Participations, Release, and Medical Agreement While we make every effort to provide a safe and pleasant environment for every participant who attends the Courageous Moms Retreat, we do require that this participation agreement be read, filled out, signed, and dated by all participants) who wish to participate in activities . With full knowledge, I accept full responsibility for any injury or accident that may occur to myself while participating in retreat activities. I give my permission to participate in activities that occur at the retreat. These activities may include, but are not limited to, nature based and mindfulness activities, ziplining, water tubing and hiking. Although the Courageous Moms Retreat coordinator has taken reasonable steps to provide equipment and skilled workers so you can participate in activities for which you may not be skilled in, we do remind you that these activities are not without risk. Certain risks cannot be eliminated due to our camp's rural setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks. For promotional or marketing purposes, Courageous Moms Retreat reserves the right to use any audio, video, and/or photography of guests or campers participating in retreat activities. I hold harmless Courageous Moms Retreat (Legacy Empowerment Services) for any and all claims for injuries, causes of action, or liability related to my participation in any activity. This release does not apply to intentional and/or willful acts of misconduct by retreat coordinator. By signing this document, I acknowledge that if anyone is hurt or property damaged during my participation in these activities, I may be found by court of law to have waived any right to maintain a lawsuit against Courageous Moms Retreat (Legacy Empowerment Services) on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound to its terms.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Payment: Payments can be conveniently made via Paypal or Zelle. Your registration at the 2022 Courageous Moms retreat is not secured until paid in full. Paypal: @rehabilitateyourlife; Zelle: 917-916-9115
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Basic Registration Fee $ 135.00
Your basic registration fee includes accommodations at our private, safe primitive campsite, nature and mindfulness based activities (guided meditation, yoga, hike and swim at Little Bradley waterfall), bonfire, girl talk/game night, goody bag and meals (continental breakfast, dinner, snacks.) LUNCH ON YOUR OWN. We will lodge in a spacious pop-up group tent; to sleep comfortably you only need your sleeping bag and pillow. You have the option to bring your own tent based on your needs. **The campsite offers a limited number of cottages for an additional $110-175 based on cottage style. Please contact me separately to request an add on of this accommodation. FAQs: yea, we're sleeping under the stars this year....it's going to be an amazing experience for you!!! ;0). Our campsite is primitive but is situated on a beautiful campground. There is nearby access to a water spigot, bathroom and shower. WIFI access is limited-COME WITH THE INTENTION TO DISCONNECT AND RECONNECT TO YOURSELF!

Basic Registration Fee
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Lower Green River tubing experience $ 25.00
This add-on covers registration for an approximately 1hour float down the Lower Green river. Included is the tube rental, shuttle to site and life jacket. This experience is the perfect way to disconnect from the chaos of your world while relaxing down the easily navigated, scenic, 1.5 mile route. FAQs: IF SELECTING THIS EXPERIENCE PLEASE ARRIVE ON TIME FRIDAY THE 27TH. The Lower Green River is a natural river so you may at times experience fast-moving water, rocks, deep spots, trees and other obstacles. You will be asked to ALWAYS wear your provided safety vest. BE READY TO GET WET!! Check out the weather and dress appropriately. You may find it helpful to bring: sunscreen, towels, change of clothes, river shoes or shoes with a strap, water bottle that can be clipped on to your bathing suit or tube, a favorite life jacket if needed.

Ultimate Zipline & Canopy Tour $ 140.00
Ziplining is a great way to enjoy nature. We will begin our 3.5 hour tour perched on the rim of the famous Green River Gorge and plunge into untouched wilderness featuring 11 ziplines, a sky-bridge, and 3 huge rappels. The Gorge offers unique perspectives and dramatic affects. Comprised of tree-based platforms, The Gorge drops an unprecedented 1,100 vertical feet from start to finish. Experience breathtaking views of 18,000 acres of protected forest and hear the roar of the Green River. GET READY FOR THE RIDE OF YOUR LIFE! FAQs All participants must weigh between 70 and 250 lbs, and we discretely verify weight at check in. Our canopy tour will run rain or shine, in all weather conditions, unless extreme winds or lightning interfere with operational safety. WHAT TO WEAR: Check the local weather before you come (zip code 28773). Wear appropriate clothing for the conditions. Close-toed footwear that is suitable hiking on variable terrain is required. Avoid wearing loose clothing, such as ponchos, scarves, and excessively baggy clothing. Short shorts are not recommended. Due to the nature of the ride, we recommend that participants leave valuables such as jewelry and cell phones in their car.

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Courageous Moms Retreat '2022 Registration Form

Payment: Payments can be conveniently made via Paypal or Zelle. Your registration at the 2022 Courageous Moms retreat is not secured until paid in full. Paypal: @rehabilitateyourlife; Zelle: 917-916-9115