Form

GENERAL INFORMATION
Full Name (as it appears on your Driver's License): *
Address: *
City: *
State: *
Zip code: *
Country: *
E-mail: *
Home Phone: *
Cell Phone:
Age *
Sex *	Male Female
Are you currently courting someone? *	Yes No
Are you currently engaged? *	Yes No
Are you single (never married, widowed, legally documented divorced)? *	Yes No
How did you learn about this Retreat?
Arrival Date
Departure Date
Mosque # or Study Group: *
Mosque/Study Group, City, State: *
Captain contact information:
Are you in good standing in your Mosque? *	Yes No
HEALTH INFORMATION
Do you have any special health conditions or needs that we should be aware of? *	Yes No
If so, please explain
Are you a licensed doctor, nurse, counselor, psychiatrist, or psychologist?	Yes No
In case of emergency, contact: *
ACTIVITIES
Are you physically able to participate in a moderately physical activity? *	Yes No
During free time, there are many activities available. Please choose 2 so we can gauge attendance:	Hiking Trail Tennis Racquetball Volleyball Study Circle Relax - whatever you wish
Check if you will participate in these activities:	Sauna (open all day) Fitness Center (open all day) Yoga and fitness (free/offered every morning for brothers and sisters) Massage (price range $45-145) Golf (price $54.60)
*Massage and golf are not included in Retreat Fees.
TRAVEL/TRANSPORTATION
Transportation this year will require a nominal fee of $10. Please see website for further information.
Will you require transportation to/from the airport? *	Yes No
So we can determine parking areas, will you be driving to the Retreat? *	Yes No
ACCOMMODATIONS
Commuter (Atlanta Residents ONLY)	$158.17 - not staying on site (no deposit required)
All rooms are single or double occupancy	$275.50 - Double Room (½ to register - $138.00 ) $398.60 - Single room (½ to register - $199.30) $418.60 - PURE Room (single) (½ to register - $209.30) $315.50 - PURE Room (double) (½ to register - $157.75)
Total Retreat fee: $275.50 per person, double occupancy (includes accommodations, activities, use of facilities, dinner, refreshments, and registration fees)
Name of preferred roommate (include full name, city, state if different from yours)
FEES
Deposit: $138 or ½ of total fees due by June 30th to hold your place (registrations will only be accepted if accompanied by a deposit or full Retreat fee).
All fees are due by July 22, 2008. After this date, hotel rooms will be released to the public and available on a first come-first serve basis so we urge you to reserve your room before the deadline!
Register and pay online or please send in a money order or cashiers check only to:
Healthy Relationships Initiative
2716 Ward Lake Ct. Ellenwood, GA 30294
DISCLAIMER, DEPOSIT AND CANCELLATION:
As a participant of the 2008 Healthy Relationships Retreat, I agree to be solely responsible for and indemnify, defend, and hold harmless all of the staff and volunteers of the Healthy Relationships 2008 Retreat. This includes the Healthy Relationships Initiative, Inc. Staff, the entire Nation of Islam, its owners, operators, employees, officers, and agents, for all loss or damage originating from or in connection with, all activities of the Healthy Relationships 2008 Retreat, the Thayer Lodging Group and Wyndham Hotel Management, Inc., or any of its contractors or affiliates for all claims or demands for damages to property of for injury or for death of persons directly or indirectly resulting from such activities of whatsoever nature (except loss or damage caused by the gross negligence or wrongful act of the Healthy Relationships 2008 staff and The Thayer Lodging Group and Wyndham Hotel Management, Inc. staff and both entities owners, operators, employees, or officers).
We are not responsible for any costs you incur in preparation for your retreat. In the event that you find it necessary to cancel your participation in this retreat, we must receive written notice of your cancellation by mail or email. Your refund will be determined by the date that we receive notification.
Consult the following timetable:

I have read, understand, and agree with the information regarding: Retreat fees, indemnification, disclaimer policy and refund guidelines.
Please choose *	Agree Disagree