Healing Hearts: A Grief & Loss Workshop

...

...

* These fields are required

1 Welcome

2 People in your group

3 Participant Info

Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone *
How did you hear about us? *
Email newsletter	Please send me the email newsletter
Some retreat locations require walking on a sloped surface and climbing stairs, are you physically able to meet this requirement? *	Yes No
Name of the person you have lost, their age when they passed, and the approximate date of their passing? *
What is your relationship to the person who passed: *	Spouse/Partner Parent Child Friend/Family Member
No Lunch Acknowledgement *	I understand lunch is not being provided for this event.
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.

4 Donate

5 Payment