Retreat @ Rock N Refuge

Guest Information

Name

First NameLast Name

Email

example@example.com

Cell Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name

First NameLast Name

Phone Number

Have you been to a retreat before?

If yes, what type of retreat?

Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)

Women: Are you pregnant or is there any possibility of being pregnant? If Yes, please indicate your due date

Date

Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.

Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)

What inspired you to come to this retreat?

READ CAREFULLY

WAIVER AND RELEASE OF LIABILITY

In consideration of my use of the premises of Rock ‘N Refuge, LLC (“Rock ‘N Refuge”) at 9128 Bold Springs Road, McEwen, Humphreys County, Tennessee 37101 and 90 James Wallace Road, McEwen, Humphreys County, Tennessee 37101 (collectively the “premises”), including but not limited to renting and/or occupying a rental property and any and all activities on the premises, (herein after referred to as the “use of the premises” or “using the premises”), I, the undersigned, agree as follows:

I have read and reviewed the Rock ‘N Refuge Rules, or have had them read and/or explained to me, and I agree that I will comply with and be bound by all requirements and terms thereof.

I do for myself, my personal representative(s), my heirs and assigns, and any minor child listed below, hereby agree to defend, release, waive, hold harmless, indemnify, covenant not to sue, and forever discharge Rock ‘N Refuge, its members, officers, employees, agents, successors and assigns, from and against any and all claims, demands, actions, or causes of action, whether on account of damage to or loss of personal property, personal injury, illness, death, or otherwise, arising from the use of the premises, including by way of illustration and not limitation, any such claims, demands, actions, or causes of action attributable, in whole or in part, to the negligence or other conduct of the members, officers, employees, and agents of Rock ‘N Refuge or any other persons or entities.

I fully understand and acknowledge that the use of the premises includes certain risks and dangers that may result in injury or illness, including but not limited to bodily injury, other ailments that could cause serious disability, or death, and that these risks and dangers may be caused by the negligence or other conduct of the members, officers, employees, and agents of Rock ‘N Refuge, the negligence of other persons or entities, my own negligence, accidents, forces of nature or other causes and may arise from foreseeable or unforeseeable causes. In full recognition and appreciation of the risks and dangers inherent in the use of the premises and in the circumstances to which I may be exposed during my use of the premises, I hereby assume all risks and dangers and all responsibility for any and all losses and damages, whether caused in whole or part by the negligence or otherconduct of the members, officers, employees, and agents of Rock ‘N Refuge, or by any other person or entity, and hereby release and discharge Rock ‘N Refuge, its members, officers, employees, agents, successors and assigns, from any and all liability therefor.

If the person using the premises is of minority age, the undersigned parent or guardian hereby agrees to and assumes the terms, waivers, releases, and undertakings as set forth above, and agrees to indemnify and hold harmless Rock ‘N Refuge, its members, officers, employees, agents, successors and assigns from and against any and all claims, demands, actions, or causes of action, arising from the minor's use of the premises.

I ACKNOWLEDGE AND AGREE THAT I HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS OF THE ABOVE WAIVER AND RELEASE OF LIABILITY AND EXECUTE THE SAMEAS MY OWN FREE WILL.

Signature