First Responder Wellness Alumni Retreat

* These fields are required

1 Your Contact Info

2 Cost

3 Your Registration Details

Cell Phone *	FORMAT: 000-000-0000
Your profession? *	Police Fire Other
Other profession? *
Work status? *	Active Retired Other
Other work status? *
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.
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. *
How long were you in the program? *
Other days in program? *
What date did you discharge the program? *
Treated for? *	Addiction Mental Health Addiction & Mental Health
Sober date? *
Please explain your current life situation? *
After leaving FRW how has your life been? *
What current challenges/struggles are you facing? *
What are your goals for attending the alumni retreat? *
Testimonial	While you are here at the FRW Alumni Retreat, we would love the opportunity to hear about your experience at First Responder Wellness. We hope to film brief alumni testimonials to share your journey with other First Responders who may be deciding whether to seek support.
Are you interested in providing a brief video testimonial? *	Yes No

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4 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? *

5 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.

6 Billing Information

Select one ... *	1/3 deposit and monthly installments I am remitting payment 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 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 ... *
Terms and Conditions	I accept the terms and conditions. EAGLE CREEK RETREAT CENTER ASSUMPTION OF RISK, ACCIDENT WAIVER AND RELEASE OF LIABILITY I, the undersigned, in consideration of my participation in any retreat, event, or activity (collectively, “activities”) hosted by or conducted on property owned, leased, or rented by Eagle Creek, LLC, Shift Wellness, LLC, or its partner companies (collectively, “Eagle Creek”), which may include transportation to and from the Eagle Creek Retreat Center and the location of the activity/event (“activity”), do acknowledge and agree as follows: 1. I understand the nature of the Eagle Creek activities and represent that I am in good health and proper physical and mental condition to participate in these activities. a. These activities may test my physical and mental limits and carry the potential for property damage or serious injury, including death. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including but not limited to, participants, volunteers, spectators, or the producer of the activity. These risks are inherent for participants and volunteers. b. I will inform Eagle Creek staff if I believe I cannot safely participate in any activity, and I will not participate if the activities are beyond my level of skill or comfort. 2. I hereby assume all of the risks of participating and/or volunteering in this activity. I realize liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of their possible liability without fault. I acknowledge this form will be used by the activity holder, sponsors, and organizers in activities in which I may participate and that it will govern my actions and responsibilities at said activity. 3. I understand that while Eagle Creek activities aim to support the mental wellness of participants, these activities are not a substitute for personalized psychiatric or medical advice, diagnosis, or treatment of any type. I take full responsibility for seeking medical treatment, counseling, or psychotherapy at my own cost for any emotional issues that arise during or after the event or activities. 4. In consideration of permitting me to participate in the Eagle Creek activities, I take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: a. Waive, release, and discharge from any and all liability for death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter accrue to me participating in this activity, the organizer and the following entities or persons: Eagle Creek, LLC, their directors, officers, affiliated clinicians and instructors, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, event volunteers, and event officials. b. Indemnify and hold harmless the entities or persons mentioned in this section from any and all liabilities or claims made by other individuals or entities as a result of my or any actions during these activities. c. If, despite this release, I or anyone on my behalf makes a claim against any of the entities or persons mentioned in this section, I shall indemnify, defend, and hold harmless each from any loss, liability, damage, or cost (including attorney’s fees) which any may incur related to such claim. 5. In the event of illness or injury during which I become unconscious or otherwise unable to verbally consent, I do hereby consent to all reasonable treatment, hospital care, and emergency transportation considered necessary in the best judgement of the Eagle Creek employees. 6. This release extends to and includes any and all claims, liabilities, injuries, damages, and causes of action that the parties do not presently anticipate, know, or suspect to exist, but that may develop, accrue, or be discovered in the future. I expressly waive all rights under California Civil Code Section 1542, which provides: “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor”. 7. I understand that I may be photographed or recorded while participating in these activities. I agree to allow my photo, audio, video, or digital likeness to be used for any legitimate business purpose, including promotional purposes in print or digital media, by Eagle Creek, LLC and other sponsors, organizers and/or assigns, and waive all rights of privacy or publicity in such materials. 8. The Assumption of Risk, Accident Waiver, and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under the laws of the State of California, and if any portion of this Agreement is held invalid, it is agreed that the balance shall notwithstanding continue in full legal force and effect. 9. I agree to comply with all precautions, safety measures, testing and disclosure requirements as set out in the Eagle Creek COVID-19 Informed Consent form, and acknowledge that although Eagle Creek will put in place known preventative measures to reduce the spread of COVID-1, Eagle Creek cannot guarantee that you will not become infected with COVID-19 while participating in Eagle Creek activities. 10. I hereby certify that I have read this document, I understand its contents, and I am signing it freely and voluntarily as a legally competent adult over the age of 18.

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7 Payment

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

Sub Total	$0

Donations	$0

Taxes	$0

33.3333% Deposit	$0
	$0 next payment date * last payment amount will be $0

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Due Now	$0 $0

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1 Your Contact Info

PLEASE READ

2 Cost

3 Your Registration Details

4 Food Allergies & Dietary Preferences

5 Emergency Contact

6 Billing Information

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

Full amount / Agency or Otherwise Funded

7 Payment

Not all programming is eligible for a discount code.