H.E.A.L.ed Women's Retreat Registration Form

H.E.A.L.ed Retreat Registration Form Oct 22nd-25th 2026 in Topsail, NC

Welcome to our faith-based 4-day, 3-night retreat. Thank you for taking this courageous first step toward healing, hope, and renewal. We are grateful that you are considering joining us. Please complete all parts of the application. Your responses will help us prepare to serve and support you during your retreat experience.
Guest Information
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Please select the option that best describes your current relationship status:

Other
How would you describe your current family and relationship situation, and are there any relationship challenges or concerns you would like us to be aware of during your retreat experience?
Have you participated in a women's retreat before?
Please share, to the extent you feel comfortable, the circumstances or challenges that led you to seek this retreat.
Please share your referral source. How did you learn about this retreat, and who (if anyone) referred you?
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.)
In case of medical emergency do you have insurance? If so who is your insurance company?
Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)
Women: Are you pregnant or is there any possibility of being pregnant? If Yes, please indicate your due date

MonthDayYear
Date
How would you describe your current relationship with God?
What is your religious affiliation or faith tradition, ie Christian, Catholic, Baptist etc.
How would you describe your current relationship with God?
List your t-shirt size
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:

As I participate in the Healed and Rooted Program, I understand that the offerings of this retreat are not a substitute for medical attention, examination, diagnosis, or treatment for mental health concerns.

I will receive spiritual and emotional related information and instruction. I recognize that I being asked to participate in all days and activities of the retreat.

I represent and warrant that I am physically and mentally able to participate and I have no medical condition that would prevent my participation in the classes or workshops.

I recognize that it is my responsibility to notify my facilitator of any serious illness or injury throughout the retreat.

I accept that neither Healed and Rooted Foundation, the facilitators, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this reatreat.

I understand that the $200 deposit for the retreat is final with no refunds and the balance of my payment is due by 1 September 2026. Cancellation fees will apply due to associated costs such as the catering service, accomodations, swag etc. I agree that all cancellations made less than three weeks in advance of the retreat be paid in full and that I may transfer my spot to another person.

Exclusion of Participation: In the unfortunate circumstance, if a guest conceals physical and/or health issues, is unfit, and/or causes disruptions that endanger the provision of the service and/or the health of other participants,facilitators, or property the guest can be excluded from the participation of the Retreat after an initial warning. If the situation arises, the contract will be terminated without further notice, already paid costs are non-refundable and incurring costs are to be paid by the guest.

I have read the above release and waiver of liability and fully understand it’s contents as well as the Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above.
Signature
Date Signed

MonthDayYear
Date
Should be Empty:

H.E.A.L.ed Retreat Registration Form Oct 22nd-25th 2026 in Topsail, NC