Hartland Lifestyle Center Wellness Hotel Application
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First Name *
Last Name *
Gender *
Date of Birth *
MM
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DD
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YYYY
Email *
Mailing Address *
Phone Number *
What is your goal when you come to Hartland Lifestyle Center? *
List any current health/medical conditions *
List all current medications/supplements *
List any and all food and medication allergies *
What is your religious preference? *
What program are you interested in? *
When would you like to visit? *
Choose preferred dates.
Terms and Conditions
1. I must be capable of self-care including eating, showering, dressing, walking, administering medications to myself, etc.
2. An informed consent and release of liability waiver must be signed upon arrival.
3. I understand that to make a reservation I need to give a deposit of $300.00 or the cost of the program (whatever is lower) and that is nonrefundable after 72 hours, but it can be applied to an upcoming program within a year from cancellation.
4. Any remaining balance is due 2 weeks prior to the program start date, this balance is non-refundable but may be transferred under special circumstances.
5. There is no 24/7 medical personnel available in the facility. I’m responsible to administer my medication, monitor glucose, as needed.
6. If hospitalized, must be 3-4 weeks post-hospitalization before acceptance to participate in any program.
7. No refund of money is given if you arrive at the lifestyle center in a worse condition than what was in the application.
8. I attest that my health condition is true to the best of my knowledge

By submitting the below registration, you agree with the above terms and conditions:
Signature *
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