Shalom Retreat Center Release of Liability: NAME * First Name Last Name WHO ARE YOU COMPLETING THIS FOR? ADULT MINOR FAMILY IF MINOR, NAME OF MINOR First Name Last Name IF FAMILY, NAME OF FAMILY REPRESENTATIVE First Name Last Name GROUP ATTENDING WITH: ARRIVAL DATE: * MM DD YYYY DEPARTURE DATE: * MM DD YYYY RELEASE & WAIVER: DO YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR EXERCISING GOOD JUDGMENT AND THAT SHALOM RETREAT CENTER IS NOT RESPONSIBLE FOR YOUR SAFETY? YES NO DO YOU RELEASE, WAIVE, AND HOLD HARMLESS SHALOM RETREAT CENTER AND EACH OF THEIR EMPLOYEES AND AGENTS, FROM ANY LIABILITY FOR LOSS OF PROPERTY OR FOR ILLNESS (INCLUDING COVID-19) OR PERSONAL INJURY THAT MAY OCCUR DURING THE ABOVE MENTIONED TIME PERIOD? YES NO MEDICAL TREATMENT: DO YOU GIVE SHALOM RETREAT CENTER STAFF MEMBERS PERMISSION TO AUTHORIZE ANY NEEDED MEDICAL TREATMENT AND DO YOU AGREE TO PAY ALL COSTS FROM THIS ACTION TO OBTAIN MEDICAL TREATMENT? * YES NO PHOTOS: DO YOU GIVE SHALOM RETREAT CENTER PERMISSION TO TAKE YOUR PHOTO FOR ADVERTISING OR MARKETING MATERIAL? * YES NO AGREEMENT: BY TYPING YOUR NAME BELOW YOU ACKNOWLEDGE THAT YOU READ, UNDERSTOOD, AND AGREE TO THE ABOVE TERMS AND THAT YOU ARE EITHER 18 OR OLDER OR ARE SIGNING ON BEHALF OF A MINOR. First Name Last Name DATE: PLEASE PROVIDE THE DATE THAT YOU COMPLETED THIS FORM. * MM DD YYYY Thank you!
