Internal Use Only Participant Liability Waiver Select the retreat you are attending:*St. John, USVICarolina Beach, NCScottsdale, AZTopsail Island, NCHatteras Island, NCSedona, AZOcean City, MDKey West, FLBlue Ridge, GACosta RicaEmerald Isle, NCOrange Beach, ALManistee, MIGrand Haven, MILake Tahoe, CASE Shoreline, CTOak Island, NCEstes Park, COBuxton, NCTemecula, CAMyrtle Beach, SCCentral Coast, CANew Smyrna Beach, FLBringing Hope HomeEach person attending the retreat over the age of 18 MUST sign this waiver to attend the retreat. Each person can sign during this online session or fill out another form at their convenience.Number of adults signing the waiver during this session.*12345678Name of all minors under this waiver. Name of Breast Cancer Participant* First Last Address of Breast Cancer Participant* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email of Breast Cancer Participant* Assumption of Risk*I (We) hereby acknowledge the activities associated with any recreational program involves an element of risk of injury. These activities include but are not limited to: swimming, stand up paddle boarding, beach volleyball, boating, walking, and arts and crafts. Little Pink Houses of Hope does not own, operate, or control the facilities where life enrichment activities are conducted. As a consequence, the below signed hereby acknowledges that he/she does hereby assume risk of any injury, illness, harm or damage of any type that may occur in the course of his/her own personal or his/her child’s participation in any Little Pink House of Hope program and release Little Pink Houses of Hope and it’s Board, Officers, Venue, Staff, and Volunteers from any liability or responsibility whatsoever. I (We) agree or disagree with the terms of the Assumption of Risk: Agree Disagree Please explain or give further information on reason for disagreeing Medical Treatment*I (We) give permission to the medical personnel selected by the LPHOH retreat leader(s) to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange related transportation for myself or child due to injury, illness, or medical emergency. In the event that I (we) cannot or any other appointed individual cannot be reached in an emergency, I (we) hereby give permission to the physician selected by the LPHOH retreat leader(s) to secure and administer treatment, including hospitalization, for the named individual(s). I (We) agree or disagree with the terms of the Medical Treatment Agree Disagree Please explain or give further information on reason for disagreeing Permission of Media*I (We) grant permission for the named to participate in any audio-visual, photo, interview, or multi-media event that may take place by Little Pink House of Hope and I (we) release everyone involved from liability or claims in association with said coverage. I (We) agree or disagree with the terms of the Permission of Media: Agree Disagree Please explain or give further information on reason for disagreeing Media Release*I (We) grant permission for any photos, audio-visual footage, interviews both recorded and printed of the named individual(s), to be used for publication in any multi-media or advertising format, such as brochures, websites, television, public service announcements, ads and publications with the express purpose of marketing and promoting Little Pink Houses of Hope. I (We) agree or disagree with the terms of the Media Release Agree Disagree Please explain or give further information on reason for disagreeing Social Media Group Sharing Release*I (We) grant permission for any photos, audio-visual footage, interviews both recorded and printed of the named individual(s), to be shared on social media by Little Pink representatives or by other retreat participants. I (We) agree or disagree with the terms of the Socia Media Group Sharing Release Agree Disagree Your contact information is for support purposes only and is not for use for economic or personal gain.I give permission for my contact information to be shared with this retreat group.*YesNoI give permission for my contact information to be shared with the LP Alumni group.*YesNo**************************************************Adult 1*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 1Adult 2*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 2Adult 3*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 3Adult 4*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 4Adult 5*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 5Adult 6*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 6Adult 7*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 7Adult 8*I voluntarily sign this waiver in favor of Little Pink Houses of Hope, Landlord/Property Donor/Owner in consideration for this retreat opportunity. I acknowledge that I have carefully read each section of this Waiver and understand its contents. I am aware that by signing this, I am waiving certain legal rights, including the right to sue Little Pink houses of Hope, the Landlord/Property Donor/Owner for any reason. Please enter your first and last name as your formal signature. First Last Cell Phone Number*Signature of Adult 8
