Retreat Participant Agreement and Release Form

Retreat Participant Agreement and Release Form
Dates you will attend:

September 20-22 Friday- Sunday, Nature's Embrace Women's Retreat at Rolling RidgeDecember 6-8 Friday- Sunday, Women's Retreat at The Land Celebration
First and Last Name of Participant
Part 1: Liability Release

You are responsible for your own well-being and safety during this weekend.
I acknowledge that outdoor activities in natural areas entail known and unanticipated risks that could result in injury. I agree and promise to accept responsibility for my own safety and well-being during this retreat. I understand that I may at any time opt to not participate in any part of the activity should I feel that it is not safe, or simply do not want to participate for any reason. I voluntarily release and hold harmless Suzanne Cervarich, Lauren Lang, the hosting property (Rolling Ridge Center or The Land Celebration Re-Creational Facility), and the individuals who are acting as guides during the retreat from any and all claims of liability which are in any way connected with my participation in this activity. If I have a new medical condition or health concern not listed on this form that I think the guides should be aware of, I will email them before the retreat and will verbally inform them at the beginning of any outdoor activity or walks that I participate in.

Yes, I agree to the above conditions.No, I do not agree to the above conditions.
Part 2: Health Questionnaire
Date of Birth
Emergency Contact Name
Relationship to Emergency Contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Alternate Emergency Phone Number
Format: (000) 000-0000.
Do you wear a Medic Alert Tag or any other marker of a medical problem?
If you do wear a medic alert tag, please describe:
Do you have allergic or anaphylactic reactions to anything, such as environmental substances, foods, drugs, insect bites or stings?
If you do have allergic or anaphylactic reactions, please describe, and let us know if you carry an EpiPen or other fast-acting medication:
Do you have any other health-related disease, condition, or concern that program guides should be aware of?
If you have any other health related conditions or concerns, please describe:
Is there anything else you would like us to know?
SIGNATURE
Part 3: Photo and Media Release
With your permission, Suzanne Cervarich and Lauren Lang may take photographs of you and the group during the activities. We would like your permission to use these photographs in promotional materials which may include social media, website, printed flyers, and videos. If you are not comfortable with having photos taken that include you and possibly used in these ways, we prefer that you mark "No" in the box below; We want you to have a relaxed and stress-free experience during your weekend.
Date

MonthDayYear
Date
By signing this form, I certify that the information I wrote on this form is accurate and complete. I agree to communicate fully with Suzanne Cervarich and Lauren Lang about any health concerns that may arise. I give my permission to Suzanne Cervarich and Lauren Lang to seek emergency medical diagnosis or treatment for me in the event that I am unconscious or unable to make my own decisions. I understand that should I need medical care for any reason while participating in this event, the role of Suzanne Cervarich and Lauren Lang will be limited to emergency first-aid and either transportation to the nearest medical facility or arranging emergency transport.
Signature
City of Residence
Should be Empty:

Part 1: Liability Release

Part 2: Health Questionnaire

Part 3: Photo and Media Release