Families with Children Retreat

Families with Children Retreat

June 23 - 26, 2026

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* These fields are required

1 Your Contact Info

PLEASE READ

As you know, federal, local, and state agency computer networks can be a bit picky, often blocking emails from unfamiliar organizations, especially those with attachments or links.

Providing a personal email address helps ensure you receive important information like confirmations, payment receipts, event details, webinar links, and in some cases forms for e-signature.

Additionally, the person listed below is considered an attendee.

First Name *

Last Name *

Email *

Confirm Email Address *

2 Details

Cell Phone *	FORMAT: 000-000-0000
Agency Name *	Please do not abbreviate.
Your Position *	(e.g.) Deputy, Police Officer, Detective, Social Worker, Sergeant, Dispatcher, etc...
Address 1 *	Example - 405 Main Street (Avenue, Lane, Circle, Trail, etc...
City/Town *
State/US Territory *
Zip Code *
What name do you prefer we call you? *	EXAMPLE - Jennifer may prefer Jenn (or) William may prefer Bill (or) some folks go by their middle name versus their first name.
How did you learn about this retreat? *	Please provide source, persons name, etc...
What would you like to accomplish during this retreat? *	Goals, etc...
T-shirt size *
Gender *
Do you have any medical or health issues that we should know about during your stay? *
List any medical or health issues. *

3 Food Allergies & Dietary Preferences

Do you have any food allergies? *
List all of your food allergies. *	Food preferences, likes or dislikes may be expressed in the last question in this section.
Do you have any other special dietary needs? *
List any other dietary needs. *	Example - Lactose intolerant, Gluten Free, or Vegan
Select the ones you eat. *	Chicken Fish Pork Beef NONE
Do you drink coffee? *
Do you put creamer in your coffee? *
What kind of coffee creamer do you prefer? *

4 Emergency Contact

	Please do not provide your information as your emergency contact.
First and Last name of Emergency Contact 1 *
Relationship to you of Emergency Contact 1 *
Phone number of Emergency Contact 1 *	Example Format: 000-000-0000 Not your phone number.
Email address of Emergency Contact 1 *	Not your email address.
Is there anything else you would like for us to know?
*SignRequest e-Signature*	Thank you for providing all of this information. You're almost done. Upon submission, you will immediately be redirected to our SignRequest page (similar to DocuSign) in order to e-sign a brief Release of Liability for our Eagle Creek Retreat Center. You know, the usual legal stuff. You are NOT required to create a SignRequest account. You will, however, need to provide your email address in order to gain access to the required form and receive your copy of the signed document.

Discount Code (if applicable)	Not all programming is eligible for a discount code.