Informed Consent Form - Pandora's Aquarium

Sponsored by Pandora’s Aquarium, Inc.
October 8-11, 2009 ∙ St. Joseph Institute ∙ Port Matilda, PA
INFORMED CONSENT FORM
(REQUIRED – INITIAL NEXT TO EACH STATEMENT)
___ I have received information about the retreat programs and location, and I warrant that I am
physically and emotionally healthy enough to participate in this retreat.
___ I understand that my participation in the retreat is entirely optional, and that I can withdraw my
participation at any time. I understand that I am not required to attend any session. If I withdraw my
participation completely and leave the retreat site, I will inform a facilitator prior to doing so.
___ I acknowledge that I have read and understand the cancellation policy.
___ I agree to abide by the laws of Pennsylvania, guidelines of St. Joseph Institute, and the safety
guidelines retreat participants will discuss at the beginning of the retreat weekend.
___ I understand that if the retreat facilitators are concerned that I pose a harm to myself or others, I
may be asked to leave the retreat site. I understand that the retreat facilitators will do what they can to
prevent this, and if it becomes necessary they will assist me in safely leaving the retreat site.
___ I understand that if I disclose an intent to harm myself or others, or if I disclose the current abuse of
a child, retreat staff may be mandated to report this information to authorities.
___ I have provided the information of a contact person, and I agree that this person can be contacted
in the event of an emergency.
___ I understand that participation in the Moving Forward retreat does not constitute psychological
treatment, but is meant to promote personal growth and foster connections. I understand that no
formal therapeutic or professional relationship will be established with any facilitator of the Moving
Forward retreat. I acknowledge that I have been encouraged to discuss my participation with my
treating counselor, if I have one. I understand that the staff of Pandora’s Aquarium, Inc., makes no
guarantee about potential benefits I will receive during my participation in the retreat. I understand
that some retreat programs will be facilitated by individuals who are not licensed counselors.

___ I understand that I will be asked to participate in sessions that may challenge me emotionally. I
understand that I will be given the opportunity to debrief with other retreat participants, facilitators,
and a professional counselor.
___ I agree to treat all information I learn about fellow retreat participants, including their names,
histories, and contact information, as confidential. I agree that I will respect fellow participants’ privacy
and I will not disclose information I learn.
___ I understand that all information I share during the Moving Forward retreat will be at my discretion.
I understand that all participants and facilitators will be asked to hold information confidential. I
understand that my confidentiality cannot be guaranteed, and I will hold Pandora’s Aquarium, Inc. and
the retreat facilitators harmless should any information about me be disclosed by retreat participants.
___ I have had the opportunity to ask any questions I have about my participation with retreat
facilitators, and I have received adequate answers to my questions.
___ I understand that support services will not be provided by retreat facilitators following the retreat’s
closing at noon on October 11, 2009. I acknowledge that I have been advised to seek support sources in
my local area both before and after attending the retreat.
___ I understand that I will receive a photocopy of this completed consent form at the commencement
of the retreat.
I, for myself, my heirs, successors, executors and subrogees, k nowingly and intentionally waive and
release, indemnify, and hold harmless Pandora’s Aquarium, Inc. and all retreat facilitators from and
against any and all claims, actions, causes of action, liabilities, expenses (including reasonable attorney’s
fees) and ordinary negligence of any kind or nature, whether foreseen or unforeseen, arising directly or
indirectly out of any damage, loss, injury, or death to me or my property as a result of participation in
the Moving Forward retreat or the use of their information or advice received from facilitator staff. I,
for myself, my heirs, successors, executors and subrogees further agree not to sue Pandora’s Aquarium,
Inc. and the retreat facilitators as a result of any emotional or physical injury or death suffered in
connection with my participation in the Moving Forward retreat.
By signing below, I assume full responsibility for my involvement in and actions during and after the
Moving Forward retreat. I have voluntarily signed this Informed Consent Form prior to participation in
the Moving Forward retreat, and certify that I have read and fully understand the content herein.
Participant Name (please print legibly): __________________________________ Birthdate: _________
Signature: ____________________________________ ______ Date:___________
Staff Signature /Date: ____________________________________________________

Please complete this consent form and send it, along with your registration form, to:
Pandora’s Aquarium, Inc.
3109 W. 50 th Street, Suite #320
Minneapolis, MN 55410
retreat@pandys.org
612-234-4204