Caregiver Registration - PossAbility Unlimited

Caregiver Details

First Name*

Last Name*

Date of Birth*

Gender*

Please specify preferred gender*

Relationship to Participant with SCI*

Email*

Phone*

Communication Preferences

I give permission to be added to the text list

I give permission to be added to the email list

Address*

City*

State*

Zip Code*

Emergency Contact Details

Doctor or Health Care Provider's Name*

Doctor or Health Care Provider's Phone*

Health Insurance Provider*

Policy or Group Number*

Emergency Contact #1

Name*

Relationship*

Phone*

Emergency Contact #2

Name*

Relationship*

Phone*

Medical Care Details

Do you ever have seizures?*

Describe seizure details

How often do you have them, are they controlled or uncontrolled and how are they treated?

Daily medication list and dose?

This is for emergency purposes only.

Dietary needs (medically necessary only)

Food allergies

Retreat Preference Details

I am comfortable being assigned to…*

Caregivers and attendees may not be assigned to the same room depending on availability

Schedules at retreats are busy and include lots of activities and fun. You will likely be up moving early and to bed late. Are you physically able to tolerate this?*

Spots for PossAbility retreats are limited and competitive. Why do you think you should get a spot? How will the retreat help you?*

Spots for PossAbility retreats are very competitive due to limited availability of spots. For that reason, we ask everyone who attends to stay for the entire retreat (Thursday at 5p EST to Sunday at 11a EST). Is that something you are willing to commit to?*

Everyone should arrive before 6p EST in time for dinner. Will you be able to make that arrival time?*

Arrival can begin at 5p EST at Bradford Woods Manor House, 5040 State Road 67 N, Martinsville, IN 46151. We cannot accommodate early arrivals.

Would you be available to an airport pickup for a retreat Participant or Caregiver from out of state if needed?*

Which of the following can you accommodate pickup for?*

Do you have any questions before the retreat?

Liability Waiver

INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE FROM LIABILITY AND AUTHORIZATION

This Informed Consent, Assumption of Risk, Release from Liability and Authorization (“Agreement”) pertains to an opportunity offered by Camp PossAbility, Inc. d/b/a PossAbility Unlimited (the “Company”) to participate in activities being offered at Bradford Woods in Martinsville, Indiana (the “Retreat”).

I wish to participate in the Retreat. In consideration of my participation in the Retreat, I hereby
agree to the following:

I understand activities for the Retreat may include, but are not limited to, the following: horseback riding, adapted ropes course, swimming, boating, outdoor sports, running, jumping, climbing, spending extended periods of time outdoors being exposed to the elements (sun, wind, rain) and consumption of food and/or beverages.
I understand that certain risks are inherent in participation at the Retreat. These risks may include, but are not limited to, such things as incidents related to the above mentioned activities, including sprains, broken bones, cuts, bruises, entrapment, temporary or permanent disability, drowning, rope burn, and/or death; adverse weather conditions; exposure to theft and other criminal activity; allergic reactions to food and drink items; other physical, mental, and emotional injury; and other risks and dangers, whether known or unknown nor reasonably foreseeable.
I shall be solely responsible for my own healthcare while participating in the Retreat activities. This includes any procedures or medication administration. I understand that if I require assistance during the Retreat, including but not limited to administration of medication, mobility assistance, or other assistance, I may have an aide attend the Retreat with me. The Company will not administer any medication or perform any procedures on my behalf. I have full permission to participate in the Retreat activities, and I am in good health.
In case of an emergency, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or the Company. In the event that this person cannot be reached, or time does not permit the person to be reached, permission is hereby given to the medical provider selected by the Company to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me. Medical providers are authorized to disclose protected health information to the Company, the Company’s medical staff, management, and/or any physician or health-care provider involved in providing medical care to me. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, et. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of me, follow-up and communication with my parents or guardian, if any, and/or determination of my ability to continue in Retreat activities. I authorize the sharing of my medical information with any Retreat volunteers or professionals who need to know of medical conditions that may require special consideration in conducting Retreat activities.
I understand that any owners, employees, officers or agents of any attraction, enterprise or vendor of which I take part or participate during the Retreat, the other participants of Retreat (whether associated with the Company or not), and other third parties (collectively, “Third Parties”), are not the agents or employees of the Company and that dangers may be caused by the negligent or intentional act(s) or omissions of such Third Parties. I understand that the Company is not responsible for any injuries or property damage that may be caused by the acts or omissions of such Third Parties.
I understand that my participation in the Retreat is entirely voluntary and at my own risk. I fully understand the scope of the activities and the potential risks involved in the Retreat. I agree to assume the risks of my participation in the Retreat, including the risk of catastrophic injury or death.
I understand and agree that the Company does not provide insurance to cover medical expenses for injuries that may be sustained by me or for damage to my personal property, and that the Company strongly recommends that I carry my own health, medical, and property insurance for purposes of potential losses related to the Retreat.
I HEREBY RELEASE AND FULLY DISCHARGE THE COMPANY, INCLUDING ITS OFFICERS, AGENTS, BOARD OF DIRECTORS, VOLUNTEERS AND EMPLOYEES, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION THAT MAY BE BROUGHT BY ME OR BY ANY OTHER PERSON (INCLUDING, BUT NOT LIMITED TO, MY ESTATE, FAMILY, SUCCESSORS, HEIRS, REPRESENTATIVES, ADMINISTRATORS, AND/OR ASSIGNS), INCLUDING ALL LIABILITY FOR DAMAGE TO PERSONAL PROPERTY (INCLUDING, BUT NOT LIMITED TO, DAMAGE TO WHEELCHAIRS, CANES, CRUTCHES AND OTHER PERSONAL MOBILITY EQUIPMENT), PERSONAL INJURY OR LOSS ARISING OUT OF OR RELATED TO MY PARTICIPATION IN THE RETREAT, WHETHER CAUSED BY THE COMPANY’S NEGLIGENCE OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW.
I hereby assign and grant to the Company, as well as its authorized representatives, the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me at all Retreat activities, and I hereby release the Company, and all employees, board of directors, volunteers, related parties, or other organizations associated with the Company from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/ videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Company, and I specifically waive any right to any compensation I may have for any of the foregoing.
This Agreement shall be governed by and construed under the laws of Indiana. Notwithstanding any other agreement that I have signed related to the Retreat that purports to establish the venue for any litigation arising from the Retreat, I agree that I will file no action against the Company or its officers, employees, and agents, whether based on this Agreement or in any way otherwise connected to the Company, in any court other than the Circuit Court of Allen County, Indiana.
I have read this entire Agreement, I fully understand it, and I agree to be bound by it. I represent and certify that my true age is at least 18 years old or, if I am under 18 years old on this date, my parent or legal guardian has also signed the Agreement.

Participant Signature*

Are you interested in purchasing a Retreat T-Shirt or making a Donation to PossAbility Unlimited?*

Hidden

Optional Registration Items

Retreat T-Shirt ($30)

Make a donation to PossAbility Unlimited

Optional Item Total

Credit Card*

Acknowledgements

PossAbility Unlimited retreats cost $40,000 for each event. This means that the spot for you and the individual you are supporting costs approximately $4,000 even though we only charge the participant $200. If you cancel, we are still paying for your spot. For this reason, if we accept you and the individual you are supporting for a spot, you acknowledge that you recognize the importance of showing up to fill your spot and guarantee that you will show up.
If you choose to leave early for a non-medical or non-emergency reason, you understand that you and the individual you are supporting will automatically be put on the waitlist for future retreats.
You agree to complete a background check prior to arriving at the retreat. (Email will be sent after registration with information)

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