Legacy Retreat Application Step 1 of 4 25% Who are you?(Required)Select your status…I am a diagnosed parentI am a caregiver/spouse to the diagnosed parentDo you have a spouse or caregiver?(Required) Yes No What is the caregiver's relationship to the diagnosed parent(Required)Select Your Status…Spouse / PartnerFamily MemberFriendIs the diagnosed parent still alive?(Required) Yes No Thank you for your interest in Inheritance of Hope. We are sorry to hear that you have lost your loved one! Currently, we are only accepting Legacy Retreat applications from families who are still living with a terminal illness. However, we would still love to connect with you so please take a look at our other offerings on our “Connect” page.Is the diagnosis life-threatening?(Required) Yes No Thank you for your interest in Inheritance of Hope. We exist to serve families who have a parent with a terminal illness. Thankfully that is not you and we hope and pray that it never is! For other ways to be connected to Inheritance of Hope visit our “Connect” webpage.What is the diagnosis (type/stage)?(Required)Does the family have children 18 or younger?(Required) Yes No We are so sorry to hear about your diagnosis, but so glad you are being proactive in finding support for your family. One of our qualifications for Legacy Retreats is that families have at least one child that is 18 or younger. However, Inheritance of Hope DOES offer other programs that could benefit your family. The best fit would likely be in Groups, which are online weekly gatherings. Signing up doesn’t commit you each week, but means you will come when you can and be welcomed with open arms–and there are lots of times/options! We are sorry that we can’t support your family through a Legacy Retreat, but we sure hope you join our online community of folks who understand what you are experiencing. Diagnosed Parent InfoName(Required) First Last Do you have a child with the same first and last name as you? Yes Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleEmail(Required) Mobile(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Spouse/Caregiver Info:Name(Required) First Last Do you have a child with the same first and last name as you? Yes Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleEmail(Required) Mobile(Required)Same address as diagnosed parent? Yes Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Children InfoName(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildDo you have any additional children? Yes No How many additional children?Please enter a number from 1 to 9.Not including the child listed above! If you have more than 9 additional children, please email LegactRetreats@inheritanceofhope.org with the additional details.Child 2Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 3Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent GenderMaleFemaleSpecial Needs for the ChildChild 4Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 5Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 6Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 7Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 8Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 9Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the ChildChild 10Name(Required) First Last Select all that apply for this child:This information helps us accurately distinguish individuals. is a twin (shares a birthdate, including year, with a household member) has the same first and last name as a parent Birth Date(Required) YYYY dash MM dash DD GenderMaleFemaleSpecial Needs for the Child Finishing UpHow did you hear about Inheritance of Hope?(Required) Facebook Post/Ad Instagram Google Ad LinkedIn Internet Search Friend/Family Member Served Medical Professional/Social Worker Other SMS Opt-In(Required)By providing your/your family’s phone number(s), you agree to receive text messages from Inheritance of Hope. Message & data rates may apply. Message frequency varies. Reply STOP to opt out, reply HELP for help Opt-InMy family is interested in attending a Legacy Retreat; this is the best way to contact our family when a spot becomes available(Required) Email Phone I understand I am responsible to arrange and pay my own travel to and from the event, including airfare if applicable. Yes Release Agreement(Required)A) I understand that participation in an Inheritance of Hope event 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 event. C) I understand, recognize, and agree that there are dangers, hazards, and risks associated with participation in the event. I understand that participation in the event 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 event and voluntarily assume the risks associated with participation in the event. 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 event. D) I understand, recognize, and agree that I am fully responsible for my child(ren) throughout the event. E) 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 event experience and Inheritance of Hope. F) By my signature set forth below, I the Applicant understand that I am unconditionally, irrevocably, and absolutely authorizing 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. G) I agree that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of South 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 event must be submitted to binding arbitration in accordance with the applicable rules of the American Arbitration Association. Any arbitration shall be sited in Oconee County, South Carolina. AcceptInformed Consent Agreement(Required)A) I understand, recognize, and agree that Inheritance of Hope employs a variety of facilitators in order to provide a quality experience to all Participants. I understand that I can request information regarding my facilitators’ education and experience backgrounds from Inheritance of Hope. B) I understand, recognize, and agree that a safe group environment is created and maintained by both the facilitators and the group members offering mutual respect and trust. Confidentiality is also primary for a safe group environment. Group facilitators are bound by law to maintain confidentiality. Participants are bound by honor to maintain confidentiality. Should I desire to share what I learn in group, I agree to do so without using group members’ names or in any way compromising group members’ confidentiality. I acknowledge that there are legal and professional limits to confidentiality. I understand that I can request more information about these limits from Inheritance of Hope. C) I understand, recognize, and agree that my children and/or teenagers will have age-appropriate group experiences for healthy emotional processing. The above elements also apply to children and teenager groups. I understand that children and teenagers will not focus on specific details of any parent’s illness but will address the fact that all have an ill parent in common. D) I understand and agree to all terms of event group participation. I also understand and agree that any Participant can contact Inheritance of Hope for more information about any aspect of the group experience. AcceptDigital Signature(Required)Signature Date(Required) MM slash DD slash YYYY CAPTCHA