Legacy Retreat Registration - FL - Inheritance of Hope

Legacy Retreat® Registration

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*

How many people are you registering?
(including yourself) Required*

Comments

Family Info:

First Name* Required*

Last Name* Required*

E-Mail* Required*

T-Shirt Size* Required*

Has your address recently changed?* Required*

Yes

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Please list any allergies or dietary preferences*
(Type n/a if not applicable) Required*

Is there anything special to note that will help us serve your family?*
Ex. Olivia has non-verbal autism and requires sensory accommodations.
(Type n/a if not applicable) Required*

What name (first & last) do you want on your name tag?* Required*

Please share a photo of your family with us! Link Required*

Uploaded

What last name would you like us to use to refer to your family?*
Ex. Type Smith to be called "The Smith Family" Required*

Additional Family Member Info:

First Name* Required*

Last Name* Required*

What name (first & last) do you want on their name tag?* Required*

T-Shirt Size* Required*

Please list any allergies or dietary preferences*
(Type n/a if not applicable) Required*

Is there anything special to note about this individual that will help us serve your family?*
(Type n/a if not applicable) Required*

Please list 1-3 close friends or family who love and care about you:
We will be reaching out for help with a special project

Close Friend/Family Info:

First Name* Required*

Last Name* Required*

E-Mail* Required*

Phone* Required*

Relationship to the diagnosed parent* Required*

Close Friend/Family Info:

First Name Required*

Last Name Required*

E-Mail Required*

Phone Required*

Relationship to the diagnosed parent Required*

Close Friend/Family Info:

First Name Required*

Last Name Required*

E-Mail Required*

Phone Required*

Relationship to the diagnosed parent Required*

Emergency Contact:
Someone who is not on the retreat*

First Name* Required*

Last Name* Required*

E-Mail* Required*

Mobile* Required*

Relationship to the diagnosed parent* Required*

Travel Info:

Venue Arrival Time Required*

Venue Departure Time Required*

Travel Method and Notes Required*

Agreements and Submission:

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*

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

Family Info:

First Name* Required*

Last Name* Required*

E-Mail* Required*

T-Shirt Size* Required*

What are your roles on this retreat?* Required*

Family Volunteer

Facilitator

Navigator

Photographer

Staff

Has your address recently changed?* Required*

Yes

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Please list any allergies or dietary preferences*
(Type n/a if not applicable) Required*

Is there anything special to note about you?*
Ex. I have non-verbal autism and require sensory accommodations. Required*

Is this your first time serving on a Legacy Retreat?* Required*

Yes

Is there any information that would help us pair you with a partner and family to serve?*
Ex. I prefer to work with teens. Or I do well with a partner who can handle all the "technology".
(Type n/a if not applicable) Required*

What name (first & last) do you want on your name tag?* Required*

Emergency Contact:
Someone who is not on the retreat*

First Name Required*

Last Name Required*

E-Mail Required*

Mobile Required*

Relationship to you Required*

Travel Info:

Venue Arrival Time Required*

Venue Departure Time Required*

Travel Method and Notes Required*

Agreements and Submission:

Release Agreement* You must agree to the term*

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 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 phone number, 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*

Signature* Required*

Signature Date* Required*

Comments

Family Info:

First Name* Required*

Last Name* Required*

E-Mail* Required*

Mobile* Required*

Birthdate* Required*

Gender* Required*

T-Shirt Size* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Do you have any allergies or special dietary needs?* Required*

Is there anything special to note about you?*
Ex. Olivia has non-verbal autism and requires sensory accommodations. Required*

What name (first & last) do you want on your name tag?* Required*

Travel Info:

Venue Arrival Time* Required*

Venue Departure Time* Required*

Travel Method and Notes Required*

Agreements and Submission:

Release Agreement* You must agree to the term*

Informed Consent Agreement* You must agree to the term*

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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