First Responder Spouse Retreat
October 3 - 6, 2024
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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
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2
Cost
$3,500.00
– Includes food/lodging, activities, and programming.
$3,500.00
$3,500.00
– Includes food/lodging, activities, and programming.
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3
Your Registration Details
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
*
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4
Info About You
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 factors led you to sign-up to attend?
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.
*
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5
Food Allergies & Dietary Preferences
Do you have any food allergies?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Do you put creamer in your coffee?
*
Yes
No
What kind of coffee creamer do you prefer?
*
Please list any additional allergies or dietary needs we should be aware of.
*
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6
Emergency Contact
Please do not provide your information as an 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.
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7
Billing Information
Select one ...
I am paying the balance due with a credit card
I am paying a deposit/monthly payments with a credit card
My agency or another entity will remit payment
Full amount / Credit Card
Registrants pay the full amount with a personal credit card or one belonging to a third-party; such as an employer.
Deposit with installment payments / Credit Card
Pay one third (⅓) of the total cost today. The remainder is divided into equal payments and automatically charged to the card on file on the same date each month. The last payment will be between 30 and 90 days
after
the start date of the program. You may make this selection below and see the calculations before making your decision.
Full amount / 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.
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8
Payment
Sub Total
$0
Taxes
$0
33.3333% Deposit
$0
$0
next payment date
* last payment amount will be
$0
Pay
Full amount
Deposit
Choose to pay a deposit or the full amount right now.
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.
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