Registration Form
We’re so honored you’ll be joining us. Our hope is that this retreat offers you solace, inspiration, and — most importantly — genuine connection with other mothers who understand. To help us create the most meaningful and personalized experience for you, please take a few moments to complete the form below. Welcome to Wild Life. We’re so glad you’re here.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Back
Next
Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Child's Full Name
*
First Name
Middle Name
Last Name
Nickname
Please Upload 8-10 Photos of Your Child
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of birth
/
Month
/
Day
Year
Date
Date of Passing
/
Month
/
Day
Year
Date
Do you have any dietary aversions, restrictions or allergies? (We will do our best to accommodate you.)
Back
Next
Welcome Gift T-shirt Size
XS
S
M
L
XL
XXL
XXXL
How did you hear about us?
*
What are you most looking forward to at this retreat?
Back
Next
Digital Photo/Video Release Form
By agreeing to this release, I authorize Wild Life Retreat to use my image in photographs, videos, or other digital media for any of its publications, including web-based publications, without any payment or compensation. I understand and agree that all photos become the property of Wild Life Retreat and will not be returned. I also give Wild Life Retreat permission to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. I waive the right to inspect or approve the finished product in which my likeness appears and any right to royalties or other compensation related to the use of the photo. By agreeing to this release, I release Wild Life Retreat from all claims and causes of action related to this authorization.I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Back
Next
Adult Participation Release & Waiver of Liability and Indemnity Agreement
PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING WILD LIFE RETREAT FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORAssumption of RiskI acknowledge and agree that any use of Wild Life Retreat facilities, services, equipment and premises (“Facilities”) and any participation in Wild Life Retreat programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease including, without limitation. I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.Waiver, Release, Indemnification & Covenant Not to SueIn consideration of the use of Facilities and participation in Programs I, the undersigned, agree that Wild Life Retreat, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releases”) will not be liable for any personal injury, property damage, disability, death, sickness of disease incurred by myself, my family members, dependents, or guests, including minors, however occurring including, but not limited to the negligence of Releases. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Programs.I further agree, on behalf of myself and any legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE, AND COVENANT NOT TO SUE Releases from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and legal successors and proxies may have, now or in the future, against Releases on account of personal injury, property damage, disability, death, sickness, diseases or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releases.In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releases from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents or guests, including any minors.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: