Select the event you are attending*IntensiveBeyondSelect Event Dates*Sept 7th - 10th 2023 (DC Intensive) Potomac Park Retreat Center 11 Tabernacle Way, Falling Waters, WV 25419Sept 22nd - 23rd 2023 (Colorado Beyond) Long Scraggy Ranch 20203 Spring Creek Trail, Buffalo Creek, CO 80425April 11th - 14th 2024 (Colorado Partner Intensive) Conifer, CO 80433Select Leadership Training Dates*N/AName* First Name Middle Name Last Name Home Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* I certify that I am at least 18 years old* Yes No Medications* Food Allergies? Please list* If you have food allergies, what foods can you eat? Birthdate* MM slash DD slash YYYY Gender*MaleFemaleSpouse/First Emergency Contact* First Last Emergency Contact Phone Number*Name of Physician First Last Physician Phone #Physician Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I have had a physical within the last 24 months Yes No Medical Insurance Company Policy Number Medical Insurance Phone NumberINDEMNITY AND CONTRACT AGREEMENT: I will not hold or attempt to hold Reclaim Ministries, Inc. liable for any loss, damage or injury to person or property caused by any act or neglect of other persons during the event or on or about the Property, or caused in any manner other than the willful or negligent act of Reclaim Ministries, Inc, its agents and employees, and will indemnify and hold harmless from any liability for damages or claims against Reclaim Ministries, Inc. arising out of or in any way related to any such loss, damage or injury. I release Reclaim Ministries, Inc., including its board members, volunteer staff, employees and agents, from my physical injury, including death, or illness during the event or while at the Property. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns. Authorization for Treatment: I hereby give permission to the medical personnel selected by the event director to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. I verify that I am in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the bounds of my physical health. In Colorado, participants will engage in rigorous activities at 9,000 to 14,000 feet. I agree and confirm that my health insurance and/or I am personally responsible for the expense of any medical treatment that is provided to me while attending a Reclaim Ministries, Inc. event.I agree to the Indemnity and Contract Agreement and Authorization for Treatment.* I Agree NameThis field is for validation purposes and should be left unchanged. YOUR SUPPORT MATTERS BECOME A SUPPORTER OF RECLAIM
