Boundless Love Sabbath Retreat Registration & Medical Form
September 14-16, 2018 "Broken and Poured"
Lakeshore Camp & Retreat Center, 1458 Pilot Knob Rd, Eva, TN 38333
Contact us at (901) 286-5532 or peacetreeumc@gmail.com
First & Last Name *
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Email *
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Phone Number (no dashes) *
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Mailing Address *
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Where are you on this journey? *
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How did you hear about this retreat? *
All guests will be placed in dorm style cabins with bunk beds. However, if you have any health needs requiring the use of a semi-private room, please state them below (we have a limited number of these rooms). If you are traveling with friends and would like to request a roommate, state their name below. *
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What are specific topics you hope are covered during this retreat (e.g. Foster Care, International Adoptions, Transracial Families, Infertility, Emotional Support, etc.) *
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Dietary restrictions *
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Allergies *
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Do you have any physical limitations we should be aware of? *
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Emergency Contact (Name & Phone Number) *
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Family Physician (Name & Phone Number) *
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By marking this box and submitting this form, I give my consent that, in the event that I am injured or take ill while participating in an activity related to the Boundless Love Sabbath Retreat and Lakeshore UM Camp & Retreat Center, and in the event that I cannot answer for myself in regards to medical care and treatment, reasonable medical care and treatment can be administered to myself as deemed necessary by a licensed physician. I agree to hold all persons making such decision free and harmless of any claims, demands, or suits for damages arising from the giving of such consent, as long as treatment is administered by or under the supervision of a licensed physician. I further agree to pay for any medical treatment which is not covered by medical insurance. I understand that Lakeshore UM Camp & Retreat Center's insurance covers only accidents, not illnesses and provides secondary insurance coverage only. I also consent to the use of my image or voice taken during the course of this retreat for any or all of the following: photographs, audio and/or video recordings, Peace Tree UMC's website, and any publications promoting Lakeshore and Peace Tree UMC. *
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