___ 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 <strong>Aquarium</strong>, 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 <strong>Aquarium</strong>, 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 <strong>Aquarium</strong>, 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 <strong>Informed</strong> <strong>Consent</strong> <strong>Form</strong> 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 <strong>Aquarium</strong>, Inc. 3109 W. 50 th Street, Suite #320 Minneapolis, MN 55410 retreat@pandys.org 612-234-4204
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