Fire Chief Resilience Retreat
July 9 - 11, 2024
...
...
*
These fields are required
1
Your Contact Info
The person named in this section is considered an attendee.
First Name
*
Last Name
*
Email
*
Confirm Email Address
*
Cell Phone
*
FORMAT: 000-000-0000
Continue
2
Cost
$2,500.00
– Includes food/lodging, activities, and programming.
$2,500.00
$2,500.00
– Includes food/lodging, activities, and programming.
Continue
3
Your Registration Details
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...
Address 2
Example - Apt 8, Suite 405, Unit 10, etc...
City/Town
*
State/US Territory
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
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.
What would you like to accomplish during this retreat?
Goals, etc...
T-shirt size
*
Small
Medium
Large
XL
XXL
XXXL
Gender
*
Male
Female
Do you have any medical or health issues that we should know about during your stay?
*
Yes
No
List any medical or health issues.
*
Continue
4
Food Allergies & Dietary Preferences
Select the ones you eat.
*
Chicken
Fish
Pork
Beef
NONE
Please list any additional allergies or dietary needs we should be aware of.
Continue
5
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?
*
Thank you for providing all of this information. You're almost done.
Upon submission, you will immediately be redirected to our
SignRequest
page in order to e-sign a brief Release of Liability for our Eagle Creek Retreat Center. You know, the usual legal stuff.
SignRequest is similar to DocuSign and will email you your signed copy.
You are
NOT
required to create a SignRequest account. You will need to provide your email address in order to gain access to the required form.
Continue
6
Billing Information
Select one
*
I am remitting payment with a credit card
My agency or another entity will remit payment
Credit Card
Registrants pay the full amount with a personal credit card or one belonging to a third-party; such as an employer.
Agency or Otherwise Funded
This will allow you to register without paying. We will take care of the rest with your Billing Contact. This is common when a third-party or an employer has an agreement in place with us for this specific programming.
Billing Contact Name
*
Billing Contact Email
*
Billing Contact Phone
*
Discount Code
(if applicable)
Not all programming is eligible for a discount code.
Continue
7
Payment
Sub Total
$0
Taxes
$0
Due Now
$0
$0
Choose Payment Option
Credit Card
Agency or Otherwise Funded
You will be asked for credit card details in the next step.
Click the button below to continue.
Continue
Continue
