PERSON TO CONTACT IN THE EVENT OF AN EMERGENCY
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Attendance Sheet
Please list all people in your group (Please include yourself). Up to four (4) people may share a
room. Fill in all fields clearly.
PERSON 1
PERSON 2
PERSON 3
PERSON 4
Bereavement history
Behavior/Physical/Medical
Do you have any of the following?
Please answer all.
This information helps the team assess needs and better serve you.
Release of Liability
In consideration for being allowed to participate in the Bereavement Retreat hosted by My
Covenant P l ace (hereinafter referred to as “the Retreat”), the undersigned acknowledges and
agrees to the following:
1. Voluntary Participation: I acknowledge that my participation in the Retreat is voluntary
and that I am free to withdraw at any time.
2. Assumption of Risk: I understand that the Retreat may involve outdoor activities and
emotional group sessions which carry certain inherent risks, including but not limited to
physical activity, emotional distress, and interactions with nature and other participants. I
assume full responsibility for any risks, injuries, or damages known or unknown, which I
might incur as a result of participating in the Retreat.
3. Release and Waiver: I hereby release, waive, discharge, and hold harmless M y
C ovenant P l ace, its directors, officers, employees, volunteers, agents, affiliates, and any
partnering organizations from any and all claims, demands, damages, liabilities, or
expenses arising out of or connected with my participation in the Retreat, whether
caused by negligence or otherwise.
4. Medical Treatment: In the event of a medical emergency, I authorize M y C ovenant P l ace
to seek emergency medical treatment for me and/or my dependent(s) at my expense
and understand that I am responsible for any resulting medical bills.
5. Photographic Release: I grant permission to M y Covenant Place to use photographs or
video footage taken during the Retreat that may include my image or likeness for
promotional, educational, or informational purposes, unless I explicitly decline in writing
prior to the event.
6.Legal Capacity: I affirm that I am of legal age and competent to sign this Release. If I am
signing on behalf of a minor, I affirm that I am the parent or legal guardian and have full
authority to sign this document on their behalf.
Covenant Place Bereavement Retreat Confidentiality Agreement
This Confidentiality Agreement (“Agreement”) is entered into by and between My Covenant
Place, the hosting agency of the Bereavement Retreat, and the undersigned participant
(“Participant”), effective as of the date signed below.
Purpose:
To foster a safe, respectful, and supportive environment, My Covenant Place requires all retreat
participants to maintain confidentiality regarding all personal information and shared
experiences during the retreat.
Agreement Terms:
1. Confidential Information:
For the purpose of this Agreement, 'Confidential Information' includes, but is not limited to, any personal stories, emotions, thoughts, expressions of grief, or identifying information shared by retreat participants, facilitators, or staff during the course of the retreat.
2. Obligations of Confidentiality:
● Refrain from disclosing, discussing, or sharing any Confidential Information obtained
during the retreat with individuals outside the retreat setting.
● Respect the privacy and dignity of all individuals participating in the retreat.
● Avoid recording, photographing, or posting any content related to other participants or retreat activities on social media or public platforms, unless explicit written permission is granted by those involved.
3. Exceptions:
This Agreement does not apply to information that:
● Is already public knowledge through no fault of the Participant.
● Is required to be disclosed by law or a valid court order. In such cases, the Participant
agrees to notify My Covenant Place prior to disclosure if possible.
4. Duration:
The obligation to maintain confidentiality remains in effect indefinitely, even after the conclusion
of the retreat.
5. Acknowledgment:
The Participant acknowledges the sensitive nature of the retreat and the importance of confidentiality in creating a safe and healing environment for all attendees.
By signing below, I confirm that I have read, understood, and agree to abide by the terms of this
Confidentiality Agreement.
On behalf of My Covenant Place:
