Swedish Core Leaders Renewal Retreat

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1 Welcome

2 Participant Info

Preferred name for your name tag (first name only), if different than your name provided above?
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone *
Would you like to receive our newsletter? *	Yes, sign me up No, thank you
Gender
Do you have any physical, language/speech, hearing, visual, or sensory concerns that could affect your experience in the retreat that you would like us to be aware of? *	Yes No
Please provide any reasonable accommodations you are requesting. *
Is there anything we should know to help ensure your comfort or that you would like us to know about you?
Campus Location You Work At *
What is your job title?
Your Credentials (ex. RN, NP, ARNP, MSW, etc) *
How many years have you been a health professional?
Available Dietary Accommodations: (Check any applicable) *	Vegetarian Gluten Free Dairy Free None Needed
Harmony Retreats Liability Waiver *	By checking this box you (the registrant) assume all responsibility for and all risk of illness, damage or injury that may occur as a participant in a Wellness/Cancer/Health Professional Program under the auspices of Harmony Retreats, a program of Cancer Lifeline. The registrant specifically assumes all risk for injury arising while attending classes or sessions, participating in movement exercises, using equipment, while walking the grounds or inhabiting the facilities. In consideration of being accepted as a participant in Harmony Retreats programs, the registrant, on behalf of her/himself and her/his heirs or assigns, hereby releases and discharges Harmony Retreats and Cancer Lifeline, its officers, directors, employees, agents and volunteers, from all claims, demands, rights of causes of action, present or future, whether known or unknown, anticipated or unanticipated, and resulting from or arising out of an incident pertaining to the undersigned’s participation in the programs/classes. By checking this box you attest that you have read and understand this assumption of risk agreement and release and willingly and without duress, sign it on behalf of yourself and agree to be bound by it.

3 Security Check