Upside Thinking Retreat
First and Last Name:
*
First Name
Last Name
Your Preferred Email Address:
*
example@example.com
Your Cell Number w/ Area code:
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Please enter a valid phone number.
Please provide an emergency contact name, cell number and relationship to yourself:
a. Their Full Name:
b. Their Phone Number:
c. Relationship:
Attendance
Please check if you will be joining us for the Day 3 celebration lunch:
Yes
No
Please list any of your dietary needs:
NONE
Allergies (Please List Below)
Other
Allergies – Please Specify:
Other – Write in:
Additional Dietary Comments:
Are you attending the Retreat with anyone?
No
Yes
If Yes, Name of person:
Have you booked your travel already?
Yes
No
If yes, please provide the following information:
Arrival Date:
Arrival Time:
Arriving Flight #:
Arriving City (times given may vary due to traffic/rush hour):
Bluegrass Airport, Lexington (LEX) – 50 minutes from venue
Louisville International Airport (SDF) – 90 minutes from venue
Cincinnati/Northern Kentucky International Airport (CVG) – 95 minutes from venue
How will you get to the event?
Car service (Uber, private company, etc.)
Rental car
Carpooling with another attendee
Media Release
I hereby authorize Upside Thinking, LLC (UT) to use my image/likeness/voice in still photos, slides, video productions, voice recorded productions, radio coverage, television coverage and/or any other media for the purpose of promoting UT and its programs. Additionally, I hereby confirm the consent given you with respect to your photographing me in connection with your video/television program(s) for UT event for which I have registered: and I hereby grant to you, your successor, assigns and licensees the perpetual right to use, as you may desire, all still photos/images of me, all motion pictures and sound track recordings which you may make of me, and the right to use my name in connection with Upside Thinking celebrations and promotions.
Media Release Signature:
Release and Waiver of Liability
I acknowledge that I have voluntarily applied to participate in the following activities at Summit Hills Farm, 722 Walker Parke Rd., Richmond, Kentucky, 40475 (the “Farm”), owned and operated by Lisa Marie Platske of Upside Thinking, Inc. (“Owner”).I am aware that these activities are hazardous activities and that I could be seriously injured or even killed. I am voluntarily participating in these activities with knowledge of the danger involved and agree to assume any and all risks of bodily injury, death or property damage, whether those risks are known or unknown. As consideration for being permitted by the Farm, any lessor of the Farm premises (“Lessor”), and Owner to participate in these activities and use the Farm premises and facilities, I forever release the Farm, and/or the Lessor, Owner, and any Farm affiliated organization, and their respective directors, officers, employees, volunteers, agents, contractors, and representatives (collectively “Releasees”) from any and all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives now have, or may have in the future, for injury, death, or property damage, related to (i) my participation in these activities, (ii) the negligence or other acts, whether directly connected to these activities or not, and however caused, by any Releasee, or (iii) the condition of the premises where these activities occur, whether or not I am then participating in the activities. I also agree that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives will not make a claim against, sue, or attach the property of any Releasee in connection with any of the matters covered by the foregoing release.I also agree to indemnify and hold harmless the Farm, and/or Lessor, and Owner, their trustees, directors, officers, employees and agents from any and all claims, actions, suits, costs, expenses, damages and liabilities including attorney fees as a result of this use of premises.I further expressly agree that the forgoing Release and Waiver agreement is intended to be as broad and inclusive as is permitted by the law of the State of Kentucky and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and the farm and the lessor and sign it of my own free will. I hereby authorize Upside Thinking, LLC (UT) to use my image/likeness/voice in still photos, slides, video productions, voice recorded productions, radio coverage, television coverage and/or any other media for the purpose of promoting UT and its programs. Additionally, I hereby confirm the consent given you with respect to your photographing me in connection with your video/television program(s) for UT event for which I have registered: and I hereby grant to you, your successor, assigns and licensees the perpetual right to use, as you may desire, all still photos/images of me, all motion pictures and sound track recordings which you may make of me, and the right to use my name in connection with Upside Thinking celebrations and promotions.
Date
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Month
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Day
Year
Release and Waiver of Liability Signature:
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