Participant's Name *

First Name

Last Name

Choose your retreat weekend *

July 12-14 $350 is due upon registration

July 19-21 $350 is due upon registration

Date of Birth *

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DD

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Participant's Phone *

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Parent's Name *

First Name

Last Name

Parent's Cell *

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Parent's Home Phone (if different from cell)

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PARTICIPANT GUIDELINES: The following guidelines are intended to insure the safety and success of the retreat for all participants. Please read these agreements very carefully; you will be asked to reaffirm your commitment to these agreements on opening day. *

1. I agree to be respectful to all other retreat participants, staff, and retreat facility property. 2. I agree to complete confidentiality of other participants' shared experiences. 3. I agree to participate in retreat activities and remain open minded to new experiences. 4. I agree not to use or possess drugs or alcohol. I understand that smoking is not permitted unless authorized by a parent's prior written consent, and that staff will maintain possession of such, and will arrange for supervised smoking periods. 5. I agree not to possess any weapons or engage in acts of violence. 6. I agree to remain on the premises of the retreat facility at all times.

I have read and agree to comply with all of the guidelines.

I hereby permit the release of photo/video or expressive art work of the above registered participant for retreat promotion, training or educational purposes. I understand that in order to secure a space for my teenager, the tuition for this program is due upon registration and is nonrefundable. I have read the written policies and agree to abide by them. *

I agree.

I agree, but do not permit release of photos/video.

PARENT AUTHORIZATION:The person herein described has permission to engage in all retreat activities except as noted by myself or a physician. In the event of an emergency I hereby give permission for the hospital selected by the facilitator to order x-rays, routine tests, and emergency treatment for the health of my child. In the event that I cannot be reached in an emergency, I hereby give permission for the hospital to secure proper treatment injections and/or anesthesia and/or surgery for my child as named above. *

Yes, I authorize.

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card for the full cost of the RETREAT.

July 12-14 ~$350

July 19-21 ~$350

Card Holder's Name (as shown on card) *

First Name

Last Name

Card Holder's Phone *

(###)

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Participant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Participant's Cell *

(###)

###

####

PARTICIPANT GUIDELINES: The following guidelines are intended to insure the safety and success of the retreat for all participants. Please read these agreements very carefully; you will be asked to reaffirm your commitment to these agreements on opening day. *

1. I agree to be respectful to all other retreat participants, staff, and retreat facility property. 2. I agree to complete confidentiality of other participants' shared experiences. 3. I agree to participate in retreat activities and remain open minded to new experiences. 4. I agree not to use or possess drugs or alcohol. I understand that smoking is not permitted unless authorized by a parent's prior written consent, and that staff will maintain possession of such, and will arrange for supervised smoking periods. 5. I agree not to possess any weapons or engage in acts of violence. 6. I agree to remain on the premises of the retreat facility at all times.

I have read and agree to comply with all of the guidelines .

I hereby permit the release of photos/video or expressive art work of the above registered participant for retreat promotion, training, or educational purposes. I understand that in order to secure my space, the tuition for this program is due upon registration and is nonrefundable. I have read the written policies and agree to abide by them. *

I agree.

I agree, but do not approve the release of photos/video.

Credit Card Authorization *

I authorize IGT to charge my credit card as indicated below.

Charge my credit card for the full amount of $350 for the RETREAT.

Card Holder's Phone *

(###)

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Name *

First Name

Last Name

Phone *

(###)

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I understand that by submitting my scholarship application, I may be selected to receive a $50 waiver form retreat tuition. The rest of the fee will be my responsibility, paid in full, before the time of the retreat. *

Yes, I agree.

I understand that submission of my application is not a guarantee of scholarship and I will be notified if I am selected. *

Yes, I agree.

I understand that pieces and parts of my application may be used on social media, or for advertising purposes, with the exception of any personally identifying information. *

Yes, I agree.

Everything that I have written is accurate to my best knowledge. *

Yes, I agree.

Date *

Must be completed by June 15, 2024.

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DD

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