Registration

2025 TrUnity Retreat Registration

Affiliated Organization Name(Required)

Name(Required)

First Last

Email(Required)

Cell Phone(Required)

Alt. Phone

1. Roommate Name

First Last

2. Roommate Name

First Last

Medical Release of Liability

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Doctor's Name(Required)

First Last

Medical info in case of emergency

Office Phone(Required)

Health History (in case of emergency): Please list any Special Medical Conditions

Any Medication Allergies

I hereby give consent in advance to the designated Leaders of the TrUnity Inc and to the physicians or hospitals selected by them to render first aid treatment or deny treatment as in their judgment is reasonably necessary, including, but not limited to, hospitalization, diagnosis including taking specimens, and x -rays, giving blood transfusions, and medications, anesthesia, and surgery. I understand that TrUnity Inc will attempt to contact my emergency contact before securing medical treatment, but that this consent is given in case they are not available in an emergency. I release the TrUnity Inc leaders and staff affiliated with this event from any and all claims, loss, cost, damage, or expense arising out of or from any accident or other occurrences, including viruses or infectious diseases causing injury to any person or property.

Media/ Social Media Consent Form: Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to TrUnity Inc, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the internet/social media).

This consent includes, but not limited to (check all boxes)(Required)

Permission to interview, film, photograph, tape or otherwise make a video reproduction of me and/or record my voice;

Permission to use my name; and

Permission to use quotes (or excerpts from quotes) from the event, in regards to interview(s), photograph(s), video & audio recording(s), in part or in whole, in its publications, in newspapers, magazines, and other print media, on television, radio and electronic media (includes internet/social media), in theatrical media and/or in mailings for event awareness.

Name(Required)

First Last

Date(Required)