Caregivers Retreat Application 2019 Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell NumberEmail Enter Email Confirm Email Alternate Contact NumberSocial Media Handles (please list all)BirthdateEthnicityBlack/African AmericanLatina/oWhite/CaucasianAsian/Pacific IslanderNative AmericanOtherGenderFemaleMaleGender non-conformingGender PronounShe/HerHe/HisThey/ThemEmployment InformationPlease list your occupation (skip if not employed)Emergency InformationEmergency Contact NameEmergency Contact NumberMedical Care Provider (physician name, hospital, or clinic name)Insurance ProviderMedical NumberPlease list any present or reoccurring health issues, special dietary needs or allergies?Family InformationHow many children/youth do you currently provide care for?What are the ages of the children/youth?What is your relationship to the child(ren)/youth (i.e. parent, grandparent, guardian etc.)?What school(s) does the child(ren)/youth attend?Which parenting issue(s) do you find to be the most stressful? (Please check all that apply)FinancialCo-ParentingBeing a Single ParentSchool ReadinessTime ManagementRetreat InformationWhat are you hoping to gain from this retreat?What kind of self-care practices do you currently engage in?Are you being sponsored by an organization or individual to attend this retreat? Yes No If yes, please name the sponsoring organization or individualHave you or one of your children participated in our programming before? (Check all that apply) Caregivers Retreat Educator's Retreat Oakland Freedom Schools Parent Chat n'Chews Camp Akili Do you need any special accommodations or have mobility needs? Yes No If yes above, please share the special accommodations or mobility needs you have to participate in this retreat.The name on the credit card that I'm using is:*Answering this question helps us to track your payment if paid for by another party*Flourish Agenda, Inc. is using Trumpia, a text messaging communication platform which will allow us to send you important event updates, surveys, and Radical Healing tools. If you would like to receive these updates, please use the box below to opt-in. Yes I consent to having my picture used on Flourish Agenda's marketing and social media materials. Yes No I hereby agree to release, waive and hold harmless Flourish Agenda, its' Board of Directors, employees, volunteers and contractors (collectively referred to as Releasees) from any and all liability arising from participation in Flourish Agenda retreat, workshops or any activities. This release waives all claims whatsoever, known or unknown, which may arise by participation in any Flourish Agenda activities, including injury or death to self, damage to property, however such claim may arise, including but not limited to breaches of duty (such as breach of duty of care) and acts of current or future negligence by Releases. This release waives any claims whatsoever against the Releasees arising from the actions of any other participant in the activity or any other third party. Further, this release covers all activities immediately before and after participation, including transportation to or from the event and waiting. The undersigned further agrees to defend and hold harmless Releasees, their respective officers, employees, or agents against any claim, cause, loss, cost or damage whatsoever, including attorney fees, that arises from the above-described activity. This release is specifically intended to indemnify the Releasees from any act of negligence of the undersigned.* I consent Please click "SUBMIT" below...Your application will be sent to us and you will be redirected to the Payment Page which must be completed. All major credit/debit cards are accepted as well as PayPal.