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