Back to Retreats Overview Want to join us for our next retreat? Great! Register below to get signed up as a participant. "*" indicates required fields Step 1 of 8 – Participant Details 12% Participant DetailsFirst Name*Last Name*Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*Select genderMaleFemaleOtherPlease specify preferred gender*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*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip Code* Emergency Contact DetailsDoctor or Health Care Provider's Name*Doctor or Health Care Provider's Phone*Health Insurance Provider*Policy or Group number*Emergency Contact #1Name*Relationship*Phone*Emergency Contact #2Name*Relationship*Phone* Medical Care DetailsDate of Spinal Cord Injury*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was the cause of your injury?*What level is your injury?*Is your injury Complete or Incomplete*Select choiceCompleteIncompleteHave you ever been diagnosed with a cognitive disability?*Select choiceNoYesPlease describe cognitive disability*Do you ever have seizures?*Select choiceNoYesDescribe seizure details*How often do you have them, are they controlled or uncontrolled and how are they treated?What type of wheelchair will you be bringing with you to the retreat?*Select chair typeManual ChairPower ChairDaily medication list and dose?*This is for emergency purposes only.Dietary Needs* No dietary needs Gluten free Gluten free/dairy free Severe allergy Please provide details on your severe allergy*How many people do you require for a chair to floor transfer?*I transfer myself12more than 2How many people do you require for a chair to bed transfer?*I transfer myself12more than 2Do you need stand-by care?*Select choiceNoYesSomeone to stand by during showers, transfers, etc.Are you Independent or do you require a Caregiver?*Select choiceI'm IndependentI will be bringing a caregiver with meI am semi-independent with care and would like to have volunteer help if possibleSemi-independent: does own bowel program, can transfer with minimal assist, etc.Note: Caregivers are provided on a first come/first serve basis as they are available; no spot is guaranteed if you do not have a caregiver due to limited availability.This field is hidden when viewing the formCaregiver DetailsCaregiver Full Name*Relationship*Phone*This field is hidden when viewing the formClear caregiver sectionWhat daily care needs do you need assistance with?* Dressing Getting in/out of bed Dependent transfers Partially independent transfers Stand by transfers (independent transfer, but need stand by) Shower Suppository insertion Digital rectal stimulation Catheterization Other None Describe other assistance required*I will be bringing the following supplies with me to the retreat* Transfer board Shower chair Hoyer lift Power chair Manual chair Adapted utensils Other None Please describe other supplies you will be bringing with you…*Individuals who attend PossAbility Unlimited events are typically students or professionals who are taking measures to be successful in life. Do you feel this will be a good fit for you?*Select choiceNoYesPlease describe why this will be a good fit for you…* Retreat Preference DetailsI am comfortable being assigned to…*Select room preferenceMale RoomFemale RoomCouples Room (husband/wife room; 2 couples per room)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?*Select choiceNoYesIf you could have 1:1 assist from a nurse practitioner (Lauren) during the retreat, what would you like help with? (Check all that apply)* Skin checks Bowel program Catheterization Other No assistance needed Please list other*If you could have 1:1 assist from a PT or PT student during the retreat, what skills would you like to work on?*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?*Select choiceNoYesEveryone should arrive before 6p EST in time for dinner. Will you be able to make that arrival time?*Select choiceNoYesArrival 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?*Select choiceNoYesWhich of the following can you accommodate pickup for?*Select choicePower chair user & guestManual chair user & guestEither optionDo you have any questions before the retreat?* Liability WaiverINFORMED 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. ยงยง160.103, 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* Medical Informed ConsentPossAbility Unlimited Medical Informed Consent 1. This form is called in “Informed Consent Form”. It is your health care provider’s obligation to provide you with information you need in order to decide whether to consent to medical treatment or medical procedure that your health care provider(s) have recommended. The purpose of this form is to verify that you have received this information and have given your consent to the medical treatment and/or medical procedure recommended to you. You should read this form carefully and ask questions of your health care provider(s) so that you fully understand the medical treatment or medical procedure before you decide whether or not to give your consent. If you have questions, you are encouraged and expected to ask them before you sign this Informed Consent Form. Your health care provider(s) are not employees or agents of PossAbility Unlimited. They are independent health care providers. 2. Your health care provider(s) have recommended the following medical treatment(s) or medical procedure(s): Catheterization Bowel Procedure Medication Procedure Skin Assessment (Full Body) Physical Assistance (including, but not limited to, bathing assistance, toilet use assistance, and feeding assistance) Education & Individual Personal Care Instruction (Male & Female Patient) Upon your authorization and consent, the above medical treatment(s) or medical procedure(s), together with any different or further treatment or procedures which, in the opinion of the health care provider(s) performing the treatment or procedure, may be indicated due to an emergency or newly-discovered information, will be performed on you. The medical treatment or medical procedure will be performed by the health care provider(s) named below (or, in the event the health care provider is unable to perform or complete the medical treatment or medical procedure, a qualified substitute health care provider), together with associates and assistants, including licensed registered nursing staff and volunteer staff, to whom the physician performing the medical treatment or medical procedure may assign designated responsibilities. 3. Name of health care provider(s) who is performing the medical treatment or medical procedure: PossAbility medical team; Lauren Harmison, FNP-BC PossAbility Unlimited maintains personnel and facilities to assist your health care provider(s) in their performance of various medical treatments and medical procedures. However, your health care provider(s), including licensed registered nursing staff, and volunteers in attendance for the purpose of performing medical treatment or medical procedures are not employees, representatives or agents of PossAbility Unlimited. They are independent health care providers. 4. All medical treatments and medical procedures carry the risk of unsuccessful results, complications, injury or even death, from both known and unknown causes, and no warranty or guarantee is made as to result or cure. You have the right to be informed of: The nature of the medical treatment or medical procedures, including other care, treatment or medications; Potential benefits, risks or side effects of the medical treatment or medical procedure, including potential problems that might occur; The likelihood of achieving treatment goals; Reasonable alternatives and the relevant risks, benefits and side effects related to such alternatives including the possible results of not receiving care or treatment; and Any independent medical research or significant economic interest your physician may have related to the performance of the proposed medical treatment or medical procedure. Except in cases of emergency, medical treatment or medical procedures are not performed until you have had the opportunity to receive this information and have given your consent. You have the right to give or refuse consent to any proposed medical treatment or medical procedure at any time prior to its performance. 5. Your signature on this Informed Consent Form indicates that: You have read and understand the information provided on this form; Your health care provider has adequately explained to you the medical treatment or medical procedure set forth above, along with the risks, benefits, and other information described in this Informed Consent Form; You have had a chance to ask your health care provider questions; You have received all of the information you desire concerning the medical treatment or medical procedure; and You authorize and expressly consent to the performance of the medical treatment or medical procedure. Participant Signature* Participant Release WaiverPlease download, print and sign the following participant release form and bring it with you to the retreat. Download Participant Release Form Payment DetailsHow would you like to pay your $275 registration fee?* One-Time Payment Installment Payments* Retreat Registration FeeOptional – Retreat T-Shirt ($30)Select sizeXSSMLXLXXL3XL4XLMake a donation to PossAbility Unlimited Credit Card Coupon Due Today Price: $0.00 Your first installment payment of $93 will be due today, followed by two (2) additional installments billed monthly starting next monthAcknowledgements PossAbility Unlimited retreats cost $40,000 for each event. This means that your spot costs approximately $4,000 even though we only charge you $200. If you cancel, we are still paying for your spot. For this reason, if we accept you 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 will automatically be put on the waitlist for future retreats.
