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Free to be ME BodyMind Connected
Event Registration and Waiver Form

I am so excited that you have chosen to be a part of 
Free to Be Me Bodymind Connected Retreat !

​I wanted to share a little information with you about our retreat location, food, lodging and a brief outline of our activities during the retreat.

Our time will be spent together at the Quaker Hill Conference Center, 10 Quaker Hill Dr., Richmond, In 47374.  The white building is called the Evans House. The session portion of the retreats will be held there.  It has quite a rich history which I will share with you during the retreat.
This is located in a beautiful setting with a large area to walk and experience nature’s beauty.

Just a short walk from the Evans House is Woodard Lodge.  This is where you will be sleeping.  The rooms have 2 single beds and a bathroom.  If you would like to have a room to yourself, please let me know.

Food will be provided by the chef at Quaker Hill. They use local produce that is available for the
current season. Meals provided are dinner Friday evening Sept 6, Breakfast, Lunch and Dinner
Saturday September 7 and Brunch Sunday September 8. Water and light snacks will also be
provided during breaks.
​
Please bring clothes that are comfortable and casual and match the climate. There will be time to
enjoy and spend time in nature. Comfortable walking shoes should be part of your wardrobe. (:
Bring a jacket in case you get cool. Also please bring paper and pen for anything you would like to
write.

​You may arrive at Quaker Hill anytime after 3:00pm to get settled into your room and acclimated. Our adventure will start off Friday late afternoon at 5:30 at the Evans House with Welcome and introductions followed by a dinner. After dinner we will meet again to begin our exploration into
Freedom and Connection.

Saturday, we will begin at 9am after you have had a chance to have breakfast and preparation time. This is a full day into the evening with several experiential components. Sunday will comprise a lovely brunch as well time for sharing the gifts of self- care, insights and plans to take with you to continue your journey to being courageously and authentically Free.

In preparation for the retreat, please read the information below and complete the requested contact information and sign the form.

Your safety and comfort is of the utmost importance to me. I request that you participate in only those activities that you are physically, mentally, emotionally, and spiritually able to do, and that you notify me of any restrictions you may have regarding any of the Activities, and I will do my best to accommodate them. Please read the following information carefully and let me know if you have any questions before signing and returning it to me.

Release and Waiver

I voluntarily desire to participate in the Free to be Me: BodyMind Connected Retreat from Friday September 6, 2019 through Sunday September, 8, 2019. ( the “Event”) organized by Michele “Shelly” Acker, Imagine Living Well (the “Facilitator”), AIso presenting are Ryan Acker, All People Thriving and Abby Potash LSW In exchange for participation in the Event and/or use of the property, facilities, and services provided during the
Event, I agree to the following:

1. ​Voluntary Participation & Assumption of Risk. I take full and sole responsibility for my life and well-being and all decisions made before, during and after the Event. I acknowledge that I am choosing to participate voluntarily in the activities at the Event (“Activities”) and I recognize that these Activities, while planned with care and love, may contain certain inherent risks. I agree that I expressly assume the risks of the Event and all Activities in which I participate. I am also aware that if there is any Activity that I am not comfortable participating in, that I may voluntarily decline to participate if I wish.
2. Rules and Warnings. I agree to observe and obey all posted and announced rules and warnings, and further agree to follow any instructions or directions given by the Facilitator, or his/her employees and agents.
3. Not a Substitute for Medical Advice. I understand that the information provided at or in conjunction with the Activities and Event is not intended to be a substitute for professional medical advice, diagnosis or treatment that can be provided by my own physician, therapist, licensed dietitian or nutritionist, or any other licensed or registered mental or physical health care professional. I understand that the Facilitator and his/her employees, representatives and agents are not acting in any capacity as a medical or mental health care provider and they are not giving medical or psychological advice. I understand that they are not providing health care, medical or nutrition therapy services or attempting to diagnose, treat or cure in any manner whatsoever any disease, condition or other physical or mental ailment of the human body during the course of the Event. Rather, they are serving in their capacities as Facilitators, coaches, mentors and guides to provide me with education, information, and tools to assist me in my own self-care and healthy living.
4. Disclosure of Allergies and Sensitivities. I understand that if I am provided with meals, snacks, or exposed to other products while at the Event, I agree to disclose to the Facilitator(s) in advance any known or suspected food sensitivities or other allergies. I agree to disclose any physical limitations that may impact my breathing or movement or any other health or mental condition that may be affected during the Event. If I suspect that I have a medical or mental health emergency, issue or concern, I agree to inform the Facilitator and his/her agents immediately.
5. Seek Medical Advice. I agree to seek the advice of my physician regarding any questions or concerns I have about my specific health situation, including but not limited to possible or actual pregnancy, known or suspected food sensitivities or allergies, dietary restrictions, or any medications I am currently taking. I understand that I am advised to speak with my own physician or mental health provider before
   implementing any Activities that I learn at the Event. I agree to not disregard or delay seeking professional medical advice or stop taking any medications without speaking to my own physician or mental health care provider.
6. Imminent Harm. At any time before or during the Event, should I know or fear that I may cause imminent harm to myself, other participants, the Facilitator, or any other person, I understand and agree that I am immediately obligated to let the Facilitator know, and to remove myself from the situation in a peaceful and cooperative manner; otherwise, I consent that I may be asked to not attend the Event, leave the Event,
   and/or have immediate physical or mental health care administered to avoid causing mental or physical harm to myself or others.
7. Consent to First-Aid or Emergency Treatment. I consent to the application of first-aid or other medical or mental health services to be applied if needed in connection with an emergency health problem or potentially harmful situation during the Event, and I agree to hold the Facilitator harmless as a result of any such injury or damage I may suffer due to the application of medical or mental health services or treatment. I also agree and consent that the Facilitator may contact my Emergency Contact as shown on the bottom of this form and share detailed information about the emergency.
8. Limitation of Liability. I waive and release the Facilitator(s) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I have ever had, now have or may have in the future against the Facilitator, arising from my past or future participation in, or otherwise with respect to, anything related to and including the Activities and Event,
   including any transportation to, from and during the Event, unless arising from the gross negligence of the Facilitator.
9. ​Release of Claims. In no event will the Facilitators be liable to me or to any person for any direct, indirect, special, incidental or consequential damages for any use of, non-use, or reliance on this Event or Activity, its information, programs and/or services, including, without limitation, personal injuries, accidents, misapplication of information, or any other loss, malady, disease, difficulty, injury, or otherwise, even if I am advised of the possibility of such damages, difficulties, or injuries, whether caused by the fault of myself,
   the Facilitator, other attendees or other third parties. I agree to pay for all damages to the facilities caused by any negligent, reckless, or willful action that I may take.
10. Quaker Hill Conference Center. I Understand that I will be held financially responsible for any damages incurred by me while under my use. I understand that Quaker Hill Conference Center is a smoke free and alcohol free facility.

​I have carefully read this document and by signing below I consent to all parts of it. I understand that by signing this Event Waiver, I voluntarily surrender certain legal rights.