Fire Service Couples Workshop

Fire Service Couples Workshop

May 27 - 29, 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 Your Registration 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...
Address 2	Example - Apt 8, Suite 405, Unit 10, 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.
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

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?
Please list any additional allergies or dietary needs we should be aware of.

4 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.

5 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 commonly used when your agency has an agreement in place with us for this specific programming or a third-party has agreed to remit payment on your behalf. Select 'Agency or Otherwise Funded' as your 'Payment Option' below.
Billing Contact Name *
Billing Contact Email *
Billing Contact Phone *

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