Clone of My Release Registration Form

1
Full Name* This field is required.
First Name
Last Name
2
E-mail* This field is required.
3
Phone Number
4
City* This field is required.
5
State* This field is required.
6
Race/ethnicity:* This field is required.Select all that apply.
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
7
Gender identity:* This field is required.
Male
Female
Non-binary
Prefer not to answer
Prefer to answer (next slide)
Other
8
Prefer to answer:
9
Age range:* This field is required.
18-24
25-34
35-44
45-54
55-64
65+
N/A
10
Which adult experiences are you most interested in? (select up to 3)* This field is required.
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.
11
Which ONE adult experience are you most excited about?* This field is required.
On-the-Go Holistic
Beauty & Confidence
Shared Connection
Dignified Care
12
Do you have any allergies or sensitivities?* This field is required.
Yes
No
13
If yes, please specify:* This field is required.
Food allergies
Fragrance sensitivity
Skin sensitivity
Latex allergy
Not applicable
Other
14
Do you have any dietary restrictions?* This field is required.
None
Vegetarian
Vegan
Gluten-free
Not applicable
15
Are there any materials or activities you should avoid?* This field is required.
Fragrances
Essential oils
Cosmetic/beauty products
Adhesives
Jewelry materials/metals
Bath/body products
None
16
Is anyone in your party a person with a disability or someone who may need an accommodation to fully participate?* This field is required.
Yes
No
Prefer not to answer
17
If yes, please tell us about any accommodations that would help participation.* This field is required.
18
How did you hear about this event?* This field is required.
Our Website
Friend/Family
Community Organization
Instagram
LinkedIn
Facebook
Email
Flyer
Event Partner
Other
19
Have you participated in an Anchor'd Inc./Foundation event before?* This field is required.
Yes
No
20
Do you consent to being photographed, filmed, or recorded during the event and for those materials to potentially be shared publicly?* This field is required.
Yes, I consent.
No, I do not consent.
21
* This field is required.
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.
22
Would you like to receive information about future Anchord Inc./Foundation programs, events, and opportunities?* This field is required.
Yes
No
23
Would you like to be contacted about future programs or opportunities?* This field is required.
Yes
No
24
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.
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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.
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Signature* This field is required.
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