• GENERAL INFORMATION

  • Sex*
  • Are you currently courting someone?*
  • Are you currently engaged?*
  • Are you single (never married, widowed, legally documented divorced)?*
  • Arrival Date
     - - :
  • Departure Date
     - - :
  • Are you in good standing in your Mosque?*

  • HEALTH INFORMATION

  • Do you have any special health conditions or needs that we should be aware of?*
  • Are you a licensed doctor, nurse, counselor, psychiatrist, or psychologist?

  • ACTIVITIES

  • Are you physically able to participate in a moderately physical activity?*
  • During free time, there are many activities available. Please choose 2 so we can gauge attendance:
  • Check if you will participate in these activities:
  • *Massage and golf are not included in Retreat Fees.

  • TRAVEL/TRANSPORTATION

  • Transportation this year will require a nominal fee of $10. Please see website for further information.
  • Will you require transportation to/from the airport?*
  • So we can determine parking areas, will you be driving to the Retreat? *

  • ACCOMMODATIONS

  • All rooms are single or double occupancy
  • Total Retreat fee: $275.50 per person, double occupancy (includes accommodations, activities, use of facilities, dinner, refreshments, and registration fees)

  • FEES

  • Deposit: $138 or ½ of total fees due by June 30th to hold your place (registrations will only be accepted if accompanied by a deposit or full Retreat fee).
  • All fees are due by July 22, 2008. After this date, hotel rooms will be released to the public and available on a first come-first serve basis so we urge you to reserve your room before the deadline!
  • Register and pay online or please send in a money order or cashiers check only to:
  • Healthy Relationships Initiative
  • 2716 Ward Lake Ct. Ellenwood, GA 30294

  • DISCLAIMER, DEPOSIT AND CANCELLATION:

  • As a participant of the 2008 Healthy Relationships Retreat, I agree to be solely responsible for and indemnify, defend, and hold harmless all of the staff and volunteers of the Healthy Relationships 2008 Retreat. This includes the Healthy Relationships Initiative, Inc. Staff, the entire Nation of Islam, its owners, operators, employees, officers, and agents, for all loss or damage originating from or in connection with, all activities of the Healthy Relationships 2008 Retreat, the Thayer Lodging Group and Wyndham Hotel Management, Inc., or any of its contractors or affiliates for all claims or demands for damages to property of for injury or for death of persons directly or indirectly resulting from such activities of whatsoever nature (except loss or damage caused by the gross negligence or wrongful act of the Healthy Relationships 2008 staff and The Thayer Lodging Group and Wyndham Hotel Management, Inc. staff and both entities owners, operators, employees, or officers).
  • We are not responsible for any costs you incur in preparation for your retreat. In the event that you find it necessary to cancel your participation in this retreat, we must receive written notice of your cancellation by mail or email. Your refund will be determined by the date that we receive notification.
  • Consult the following timetable:
  • Image field 82
  • I have read, understand, and agree with the information regarding: Retreat fees, indemnification, disclaimer policy and refund guidelines.
  • Please choose*
  • Should be Empty: