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SPO Retreat Form and Liability Waiver
Please fill out and submit this form if you are attending SPO's Fan into Flame retreat for Benedictine College.
7
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1
Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Carpool Information
*
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Can you drive yourself and others to the retreat? Yes or No.
If so, how many can you fit in your car (including yourself)? Type N/A if not applicable.
Do you need a ride to the retreat center? Yes or No.
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4
Medical Insurance Information
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What is your medical insurance provider?
What is your medical insurance group number?
What is your medical insurance identification number?
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5
Emergency Contact Information
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Please list: emergency contact name, relationship to emergency contact, and emergency contact phone number
Emergency Contact Name
Relationship to Emergency Contact
Emergency Contact Phone Number
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6
Medical & Allergy Information
*
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Type N/A if not applicable.
Do you have any medical conditions or allergies that we should be aware of?
Do you have any food allergies or restrictions?
Are you currently taking any medications? Please list them.
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7
Assumption of Risk Release Form
I understand and agree that the Fan into Flame Retreat on February 8, 9, and 10, 2019, held at Three Trails Camp & Retreat Center and hosted by Saint Paul’s Outreach of which I am a participant, involves certain risks and that, regardless of the precautions taken by the above organization, some bodily injury may occur. Specific risks/hazards involved in the above event include, but are not limited to the following: Driving to and from the retreat, injuries that occur during activities, and possible allergic reactions to food or insect bites. Knowing this information, in consideration of my participation in the above event, I expressly and knowingly release Saint Paul’s Outreach, Three Trails Camp & Retreat Center and their officers, agents, representatives, advisors, directors, family members, volunteers, helpers, partners, organizational members, associates and employees, from any and all claims and causes of action for property damage, personal injury or death sustained by me arising out of any travel or activity conducted by or under the auspices of the above organizations caused by risk associated by this activity and /or the negligence of the sponsoring groups. In addition, I understand and agree that Saint Paul’s Outreach and Three Trails Camp & Retreat Center cannot be expected to control all of the risks articulated in this form, but may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required during my participation with the understanding that the cost of any such treatment will be my responsibility. Saint Paul’s Outreach and Three Trails Camp & Retreat Center do not carry any sort of medical or accident insurance for the activities mentioned, unless the participants are informed otherwise. As such, participants should review their personal insurance portfolio. Finally, I voluntarily and knowingly agree to defend, protect, hold harmless, and fully indemnify, Saint Paul’s Outreach, Three Trails Camp & Retreat Center, its officers, agents, representatives, advisors, directors, family members, volunteers, helpers, partners, organizational members, associates and employees against all claims, demands, or causes of action for property damage, personal injury, or death, arising from the negligence or fault of the above named, including defense costs and attorney fees arising out of my participation in the above event of the above organization. Additionally, I agree to defend, protect, hold harmless and fully indemnify Saint Paul’s Outreach, and Three Trails Camp & Retreat Center for any claim or cause of action whatsoever arising out of the Fan Into Flame Retreat which takes place during the above identified dates of February 8, 9, 10, 2019 that is brought against Saint Paul’s Outreach and Three Trails Camp & Retreat Center by me or a family member whether such claim arises from the alleged negligence of Saint Paul’s Outreach and Three Trails Camp & Retreat Center its employees or agents or my negligence. If any portion of this agreement is held invalid, it is agreed that the balance thereof, shall continue in full legal force and effect.I understand that this is a substance free retreat and agree not to bring and/or consume alcohol and/or any form of illegal substance during this retreat. I have read the above agreement and have willingly signed the same for the consideration expressed and with a full understanding of its purpose. Participant represents that he/she is eighteen (18) years of age or older and is otherwise competent to execute this agreement, or that his/her legal guardian is also signing this agreement.
I have read, understand, and agree to the above information. (Type your first and last name)
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