MY RELEASE
A SAFE SPACE TO BREATHE, HEAL & RECONNECT | Trauma-Informed Creative Wellness & Healing Experience designed specifically for parents and children surviving domestic violence & trauma through a supportive, uplifting environment to express, restore, and rebuild together. Presented by ANCHOR'D INC FOUNDATION
[Family]Parent/Guardian Registration
Complete this section if registering a family.
Parent/Guardian Full Name
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First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian City
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Parent/Guardian State
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How many people are you registering today?
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1
2
3
4
5
6+
N/A
Please indicate the number of adults (18+) in your party:
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Please indicate the number of children/youth (under 18) in your party:
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Parent/Guardian age range:
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18-24
25-34
35-44
45-54
55-64
65+
N/A
Parent/Guardian gender identity:
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Male
Female
Non-binary
Prefer not to answer
Prefer to answer (below)
Other
Prefer to answer:
Parent/Guardian race/ethnicity:
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Black/African American
Hispanic/Latino/a/x
White/Caucasian
Asian/Asian American
Native American/Indigenous
Native Hawaiian/Pacific Islander
Native Hawaiian/Pacific Islander
Middle Eastern/North African
Multiracial
Prefer not to answer
Which adult experiences are you most interested in? (select up to 3)
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On-the-Go Holistic Station: Simple wellness practices and tools designed to support everyday wellbeing.
Beauty & Confidence Station: An interactive experience centered on beauty, self-expression, confidence, and feeling good in your own skin.
Shared Connection Station: A space designed to encourage conversation, reflection, connection, and community.
Dignified Care Station: A self-care experience focused on dignity, personal care, and access to essential wellness resources.
Which ONE adult experience are you most excited about?
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On-the-Go Holistic
Beauty & Confidence
Shared Connection
Dignified Care
How many children/youth are you registering today?
1
2
3
4
5
6+
Child/Youth 1
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Child/Youth 2
Child/Youth 3
Child/Youth 4
Child/Youth 5
Child/Youth 6
Which child/youth experiences are you most interested in? (select up to 2)
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Bath Bomb Creation: Create your own bath bomb while exploring creativity, self-care, and wellness.
Jewelry Creation Station: Design and create a wearable piece that represents your personality, story, or identity.
My Voice Self-Expression Station: A creative space for young participants to explore identity, confidence, storytelling, and self-expression.
Which ONE child/youth activation are you most excited about?
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Bath Bomb Creation
Jewelry Collection
My Voice Self-Expression
N/A
Family Food and Beverage Preferences & Accessibility Needs
Do you or anyone in your party have any allergies or sensitivities?
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Yes
No
If yes, please specify:
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Food allergies
Fragrance sensitivity
Skin sensitivity
Latex allergy
Not applicable
Other
Do you or anyone in your party have any dietary restrictions?
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None
Vegetarian
Vegan
Gluten-free
Not applicable
Are there any materials or activities you or anyone in your party should avoid?
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Fragrances
Essential oils
Cosmetic/beauty products
Adhesives
Jewelry materials/metals
Bath/body products
None
Is anyone in your party a person with a disability or someone who may need an accommodation to fully participate?
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Yes
No
Prefer not to answer
If yes, please tell us about any accommodations that would help participation.
*
Family Release & Consent
How did you hear about this event?
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Our Website
Friend/Family
Community Organization
Instagram
LinkedIn
Facebook
Email
Flyer
Event Partner
Other
Have you or anyone in your party participated in an Anchor'd Inc./Foundation event before?
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Yes
No
Photography Release
We may photograph or record participants during the event. Images, video, audio, or other recordings may be used by Anchord Inc. Foundation and its partners for educational, promotional, archival, social media, website, marketing, grant reporting, and other public-facing purposes.
Do you consent to being photographed, filmed, or recorded during the event and for those materials to potentially be shared publicly?
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Yes, I consent.
No, I do not consent.
As the parent/legal guardian, I authorize Anchord Inc. Foundation to photograph, film, or record the minor(s) listed on this registration and use the resulting materials for the purposes described above.
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Yes, I authorize this.
No, I do not authorize this.
Privacy Consent
By submitting this form, you acknowledge that the information provided will be used to register you for the event, communicate important event information, plan event activities and resources, and evaluate participation and impact. Your information will be handled in accordance with Anchord Inc. Foundation's privacy practices and will not be publicly displayed without your consent.
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I have read and understand how my information will be used and agree to the collection and use of my information for event registration and planning purposes.
Would you like to receive information about future Anchord Inc./Foundation programs, events, and opportunities?
Yes
No
Parent/Guardian Consent
For anyone registering a minor:
I confirm that I am the parent or legal guardian of the minor participant(s) listed on this form and have permission to register them for this event.
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Yes, I confirm.
Would you like to be contacted about future programs or opportunities?
Yes
No
Terms and Conditions
I understand that registration does not guarantee participation in every activation and that some activities may have limited capacity or require participants to wait for an available space.
By registering for My RELEASE, I acknowledge that participation in the event and its creative, wellness, and interactive activities is voluntary and undertaken at my own discretion. I understand that participation may involve certain materials, activities, or interactions that carry inherent risks, and I agree to disclose any relevant allergies, sensitivities, accessibility needs, or safety concerns. To the fullest extent permitted by law, I agree to indemnify, defend, and hold harmless Anchord Inc. Foundation, its officers, directors, employees, volunteers, partners, and event facilitators from and against any claims, liabilities, damages, losses, or expenses arising from or related to my participation in the event, except to the extent caused by their gross negligence or willful misconduct. I agree to follow all event rules and instructions and confirm that the information provided in this registration is accurate.
Signature
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Submit
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