Name *

First Name

Last Name

Phone

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

###

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Photo release *

I consent and authorize Mission Flexible to use my likeness in any photograph or video taken on retreat. This material may be used for future publicity or fundraising including news media.

Agree

Disagree

Liability waiver *

Participant does hereby release and forever discharge Mission Flexible and Lisa Jakub from any and all liability, claims, and causes in action, which arise or may hereafter arise or are in any way connected to Participant’s involvement in a Retreat.

Agree

Disagree