Legacy Retreat Application - Inheritance of Hope

Legacy Retreat® Application

Our mission is to inspire hope in young families, with children 18 or under, facing the loss of a parent to a life-threatening illness.

Who are you? Required*

Comments

Is the Diagnosis life-threatening?

Yes

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.

Required*

What is your diagnosis (type/stage)? Required*

Do you have children 18 or younger?

Yes

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.

Required*

Do you have a spouse or a caregiver?

Yes

Required*

What is their relationship to you? Required*

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

E-Mail* Required*

Mobile* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Spouse/Caregiver Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

E-Mail* Required*

Mobile* Required*

Same address as Diagnosed Parent* Required*

Yes

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Children Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

Special Needs for the Child

Page 3

How did you hear about Inheritance of Hope?* Required*

Release Agreement* You must agree to the term*

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.

Informed Consent Agreement* You must agree to the term*

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.

SMS Opt-In* You must agree to the term*

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-in*

My family is interested in attending a Legacy Retreat:
(please check all that apply) You must agree to the term*

I am interested in a Legacy Retreat in 2024

and would like you to check back when future retreats are scheduled

Note: this does not guarantee your spot on a retreat but lets us know how to follow up with you!

I understand I am responsible to arrange and pay my own travel to and from the event, including airfare if applicable.* Required*

Yes

Signature* Required*

Signature Date* Required*

Comments

Is the Diagnosed Parent still alive?

Yes

Required*

Is the Diagnosis life-threatening?

Yes

Required*

What is the diagnosis (type/stage)? Required*

Relationship to the diagnosed parent Required*

Do you/they have children 18 or younger?

Yes

Required*

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Date of Death* Required*

Gender Required*

E-Mail* Required*

Mobile* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Spouse/Caregiver Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

E-Mail* Required*

Mobile* Required*

Same address as Diagnosed Parent* Required*

Yes

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Children Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

Special Needs for the Child

Page 3

How did you hear about Inheritance of Hope?* Required*

Release Agreement* You must agree to the term*

Informed Consent Agreement* You must agree to the term*

SMS Opt-In* You must agree to the term*

Opt-in*

My family is interested in attending a Legacy Retreat:
(please check all that apply) You must agree to the term*

I am interested in a Legacy Retreat in 2024

and would like you to check back when future retreats are scheduled

Note: this does not guarantee your spot on a retreat but lets us know how to follow up with you!

I understand I am responsible to arrange and pay my own travel to and from the event, including airfare if applicable.* Required*

Yes

Signature* Required*

Signature Date* Required*

If you have any technical issues with this form,
please email Tech@InheritanceOfHope.Org

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