Legacy Retreat Application

Inheritance of Hope Legacy Retreat® Application

Before working on this application, please be sure to have your family photo and completed physician letter ready to attach (upload) as files. Also have the diagnosed parent's personal notes to each child ready to attach. These materials are required to submit the application. Each file size should be under 5 MB. If your doctor is going to scan and email the physician letter to us at info@InheritanceOfHope.org, you still need to upload our form letter with this application. Simply include a note on it so we know it is pending with the doctor, and please include the doctor's phone number and email so that we can follow up on your behalf. Thanks! After you submit your application, our Legacy Retreat® staff will contact you as soon as possible using the email and/or phone number you provide.
Please attach a family photo containing all of the people who will be attending the Legacy Retreat. Please have the file name include your family's last name.**
Please attach an image under 5 MB.

Please attach your completed physician letter.**
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 1st child.**
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 2nd child, if applicable.
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 3rd child, if applicable.
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 4th child, if applicable.
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 5th child, if applicable.
Please attach an image under 5 MB.

Please attach the diagnosed parent's note to the 6th child, if applicable.
Please attach an image under 5 MB.

SECTION ONE -- FAMILY INFORMATION
Applicant First Name**
Please enter your first name.

(Parent with life-threatening illness)

Applicant Last Name**
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Applicant's Diagnosis**
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In rare situations, we allow for a non-spouse to attend the retreat as a caregiver. We expect this person to be involved in the day-to-day care of the diagnosed parent. This person should live near the family, be familiar with the family's day-to-day needs, and be experienced in meeting those needs. The caregiver will travel with the family. If the diagnosed parent does not require a caregiver for travel and would prefer to come alone with his/her children, our volunteers and staff are prepared and enthusiastic to help in every way at the Legacy Retreat®.
Spouse (or Caregiver)**
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Address Line 1**
Invalid Input

Address Line 2
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City**
Please enter your city.

State**
Invalid Input

ZIP Code**
Invalid Input

Applicant's Email Address**
Please let us know your email address.

Caregiver's Email Address
Please let us know your caregiver's email address.

Applicant's Cell Phone Number
Invalid Input

Caregiver's Cell Phone Number
Invalid Input

Home Phone Number
Invalid Input

What is the best phone number to reach you?**
Please enter a valid phone number -- example 123-456-7890.

Please list nearby airports that you could fly from, in order of your preference. For example: 1.LaGuardia LGA 2.Newark EWR 3.Kennedy JFK
1st Airport Preference**
Invalid Input

2nd Airport Preference**
Please enter a different airport option

3rd Airport Preference**
Please enter a different airport option

Your spouse/caregiver and children under 18 for whom you have legal custody may attend the retreat with you. Please enter the following information for each person planning to attend your Legacy Retreat®.
Applicant:
Name - Last, First, Middle (as it appears on gov't-issued ID)**
Invalid Input

Name for Name Tag**
Invalid Input

Shirt Size**
Invalid Input

Age**
Please enter your age in numeric format (e.g., 45)

Gender**
Invalid Input

Full Birth Date**
/ / Invalid Input

Spouse or Caregiver:
Relationship to Applicant
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

1st Child:
Relationship to Applicant (son or daughter)**
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)**
Invalid Input

Name for Name Tag**
Invalid Input

Shirt Size**
Invalid Input

Age**
Please enter your age in numeric format (e.g., 45)

Gender**
Invalid Input

Full Birth Date**
/ / Invalid Input

2nd Child:
Relationship to Applicant (son or daughter)
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

3rd Child:
Relationship to Applicant (son or daughter)
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

4th Child:
Relationship to Applicant (son or daughter)
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

5th Child:
Relationship to Applicant (son or daughter)
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

6th Child:
Relationship to Applicant (son or daughter)
Invalid Input

Name - Last, First, Middle (as it appears on gov't-issued ID)
Invalid Input

Name for Name Tag
Invalid Input

Shirt Size
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Full Birth Date
/ / Invalid Input

SECTION TWO -- EMERGENCY CONTACT (needs to be someone who is not attending the Legacy Retreat®)
Name**
Invalid Input

Relationship**
Invalid Input

Primary Phone Number**
Invalid Input

Other Phone Number
Invalid Input

Email Address**
Invalid Input

SECTION THREE -- SPECIAL NEEDS (check all that apply)

Invalid Input

Other?
Invalid Input

(Please explain -- we will do our best to meet your needs!)

SECTION FOUR -- HEALTH AGREEMENT
a. Please include with your application the completed physician letter provided by Inheritance of Hope. (Attach with uploader at bottom of form.)
b. I hereby represent and certify that each person listed on this application (“Participant”) is physically and medically able to participate in the Legacy Retreat® and has no physical or medical condition that would make his or her participation in the Legacy Retreat® unsafe or dangerous to any Participant or to others. I certify that the Applicant has been medically cleared to participate in the Legacy Retreat® and that neither Inheritance of Hope nor any of its officers, directors, employees, volunteers, agents, or representatives shall be held liable for any falsification or alteration of any such medical clearance.
c. I understand and agree that Inheritance of Hope does not have medical personnel available at the location of the Legacy Retreat®. I hereby grant Inheritance of Hope permission to transport the Applicant or any other Participant to and authorize emergency medical treatment for the Applicant or such Participant, and that such action shall be subject to the terms of this Agreement. I agree to pay for all expenses incurred for the transportation of the Participant to and the Participant’s receipt of emergency medical treatment. I understand and agree that Inheritance of Hope assumes no responsibility for any injury, damage, disease, and/or death that might arise out of, or in connection with, such authorized emergency medical treatment.
d. I represent and agree that each Participant is covered by adequate health insurance necessary to cover any and all medical costs that may be incurred as a result of or that may arise out of Participant’s participation in the Legacy Retreat®. I agree to pay for any costs related to the medical treatment of Participant that are not covered by insurance. I have attached to this signed Agreement a copy of each Participant’s medical insurance card.
SECTION SIX -- RELEASE AGREEMENT
a. I understand that participation in an Inheritance of Hope Legacy Retreat® is purely voluntary.
b. On behalf of myself and all the Participants listed on this form, their heirs, personal representatives, guardians, successors, and assigns, I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope Legacy Retreat®.
c. I understand, recognize, and agree that there are dangers, hazards, and risks associated with participation in the Legacy Retreat®. I understand that participation in the Legacy Retreat® may result in injury, property damage, interaction with persons having potentially communicable diseases, and/or death. I acknowledge that I understand and have fully considered the dangers, hazards, and risks associated with the Legacy Retreat® and voluntarily assume the risks associated with participation in the Legacy Retreat®. I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, in the event of injury, property damage, disease, and/or death related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope Legacy Retreat®.
d. By my/our signature(s) set forth below, I/we authorize Inheritance of Hope to photograph, film, and/or electronically record interviews with me/us in such a manner as they choose. I further give permission and consent that any such photographs, films, and/or electronically recorded interviews may be published and used by Inheritance of Hope and its agents to illustrate and promote the Legacy Retreat® experience and Inheritance of Hope.
e. By my signature set forth below, I the Applicant unconditionally, irrevocably, and absolutely authorize Inheritance of Hope to share the medical information contained in this application with its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries.
f. I agree that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Any claims against Inheritance of Hope arising from or related to this Agreement or the Legacy Retreat® must be submitted to binding arbitration in accordance with the applicable rules of the American Arbitration Association. Any arbitration shall be sited in Transylvania County, North Carolina.
I/we hereby warrant that I/we have read the foregoing Agreements and executed them freely and voluntarily.
Give your legally effective electronic signature below by typing your full legal name and entering the date.
Applicant Signature:**
Invalid Input

Date:**
/ / Invalid Input

Spouse/Caregiver Signature (if no spouse/caregiver will be included in the retreat, applicant must sign here also):**
Invalid Input

Date:**
/ / Invalid Input

Parent Signature of all minor children included in the retreat:**
Invalid Input

Date:**
/ / Invalid Input

SECTION SEVEN -- RETREAT INFORMATION: Please complete the following information to help us prepare the most comfortable and enjoyable retreat for you and your family.
Are there any food allergies or dietary restrictions for anyone in your family?**
Invalid Input

If "yes," please explain:
Invalid Input

Do you plan to drive to and from the retreat, as well as to the individual events during the retreat weekend?**
Invalid Input

We will be working on a special surprise and we need some help. In an effort to help us serve your family better, we would appreciate it if you could list at least three contacts who know your family well (i.e. a close relative, neighbor, school counselor/teacher, coach, pastor, co-worker, club representative, etc.). Our goal is to equip and inspire these people/groups to help your family when you need it most. Please provide the following information for each contact.
1st Contact:
Name**
Invalid Input

Email Address**
Invalid Input

Phone Number**
Invalid Input

Relationship to Family**
Invalid Input

2nd Contact:
Name**
Invalid Input

Email Address**
Invalid Input

Phone Number**
Invalid Input

Relationship to Family**
Invalid Input

3rd Contact:
Name**
Invalid Input

Email Address**
Invalid Input

Phone Number**
Invalid Input

Relationship to Family**
Invalid Input

4th Contact:
Name
Invalid Input

Email Address
Invalid Input

Phone Number
Invalid Input

Relationship to Family
Invalid Input

How did you hear about Inheritance of Hope?**
Please complete this field.

We have found that your community is interested in supporting you. If willing, please list local media outlets (e.g., newspapers, TV stations, radio stations, etc.) and other community outlets (e.g., church, work, school communities, alumni organizations/clubs, etc.) so that we can ensure their awareness of your Legacy Retreat® participation.
**
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After you submit your application, our Legacy Retreat® staff will contact you as soon as possible using the email and/or phone number you have provided.