Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Emergency Contact

First NameLast Name

Emergency Contact Phone

Please enter a valid phone number.

Age

21-3030-5050+

Gender

MaleFemale

Race/Ethnicity

Highest Level of Education

Do you require any special accommodation

Able to attend the three full days*

YesNo

If no, please explain

Briefly describe your experience, if any, with domestic violence and/or child abuse or child neglect:*

Sometimes the effects of domestic violence, abuse and/or neglect can lead to other things that may need to be addressed prior to participating in the event. Do you struggle with any behavioral health disorders and/or addictions (drug, sexual, alcoholism, food, etc.)? If yes, please describe: *

If yes, are you currently receiving care for any of the above items?*

YesNo

Are you currently in a relationship where you do not feel safe?*

YesNo

If Yes, please explain

Are you currently in a situation where you do not feel safe in your home?

YesNo

If ‘Yes’ please explain:

Are you experiencing an unusual amount of stress or significant transition in your life?

YesNo

If ‘Yes’ please explain:

Have you ever had serious thoughts of suicide or have made an attempt or a plan to in the past?

YesNo

If yes, where are you today thoughts of suicide?

Have you received or witnessed trauma within the past 12 months?

YesNo

If yes, please provide a brief description:

What does your support system consist of? (group support, counseling, partner, family, church, etc.):

I agree to:*

Attend each day and all sessionsRefrain from the use of drugs or alcoholI will not share or disclose any personal information about other participants without their consent.I acknowledge that I may be called as part of the application process and those that attend will be called within two weeks after as a part of the follow-up process

Please be advised that while we respect your privacy, we are also mandated reporters. This means we are legally obligated to report any disclosures of harm to yourself or others, including abuse, neglect, or threats of harm to the appropriate authorities as required by law.

Photography permission: Permission to LIM to use photographs, videos, or audio clips for outreach, advertising, and publications.

YesType option 2Type option 3Type option 4

Photography permission: Permission given to LIM to use photographs, videos, or audio clips for outreach, advertising, and publications.

YesNo

Signature

PARTICIPANT ASSUMPTION OF RISKS, INDEMNITY AGREEMENT AND LIABILITY WAIVER AND RELEASE

I, the undersigned, acknowledge and agree to the following terms and conditions as a condition of my participation in Tree of Life Gathering. I understand that my participation in this conference is voluntary and that I may withdraw at any time. I acknowledge that the content may involve emotional, mental, and spiritual content as part of the healing process, which may be challenging or difficult for participants. I certify that I have sufficient skill and fitness to participate in the activities offered in the Tree of Life Gathering

I understand that my participation may involve certain inherent risks, including but not limited to emotional distress, physical discomfort, or other personal reactions as I engage in the conference activities. I assume all risks associated with my participation, including any effects that may arise during or after the event.

In consideration of being permitted to participate in the Tree of Life Gathering, I hereby release, waive, discharge, and covenant not to sue Edgenuity and Tree of Life Gathering, its creators, teachers, facilitators, affiliates, employees, volunteers, and the owners of the venue/building, from any and all liability for any injuries, illness, damages, claims, or demands that I, my heirs, or any personal representatives may have arising out of or in connection with my participation in this conference. This waiver includes but is not limited to any claims for physical or emotional injury, negligence, or any other liability.

I acknowledge that I am solely responsible for my own health and well-being and that I am not under the influence of any substances that would impair my ability to participate in the event activities safely. I agree to notify the organizers immediately if I experience any health issues during the conference.

I agree to indemnify and hold harmless Edgenuity, Tree of Life Gathering, its creators, teachers, facilitators, affiliates, employees, volunteers, and venue/building ([Venue Name]) from any claims, liabilities, damages, or expenses arising from my actions or conduct during the conference.

This waiver and release shall be governed by and construed in accordance with the laws of the state of Alaska.

As lawful consideration for being allowed to participate in activities offered in the Tree of Life Gathering, I expressly agree and promise to accept and assume all the risks existing in these activities. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks. I expressly agree and acknowledge that the terms and conditions of this Assumption of Risks, Release of Liability, and Indemnity Agreement are contractual in nature and that I am signing it of my own free will.

By signing below, I confirm that I have read, understood, and agree to the terms and conditions of this Liability Waiver and Release Form.

Signature