Women’s Retreat at Our Lady of the Fields Women's Retreat Registration & Participation Waiver Attendee InformationLegal Name of Attendee* First Last NAME of parish you attend:* CITY of church or school you attend:* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your preferred email address:* Cell phone with area code:* Payment InformationHow would you like to pay?*Select a payment option.Cash or Check (At the door)Credit or Debit CardRegistration Fee Price: Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Legal InformationA confirmation message will follow once you submit this form. More information will be provided in this message. Please call our office at (248) 379-0943 with questions or send an email to [email protected] Consent* By checking this box, which represents my legal signature, I agree to accept all of the terms and conditions listed in this liability waiver for Our Lady of the Fields Camp & Retreat Center.With my signature, I give my consent, whom I identify in the above section, to participate in any and all activities and events at Our Lady of the Fields Summer Camp and Retreat Center, which is owned and operated by the St. Thomas Chaldean Catholic Diocese of West Bloomfield Township, Michigan. I agree that in order for me to participate in any and all activities and events, I must read and voluntarily agree to the following terms and conditions of this agreement. I willingly give my consent to participate in any and all activities and events at Our Lady of the Fields Camp and Retreat Center. I assert that my participation is entirely voluntary. Acting on my own behalf, I expressly acknowledge and agree that there are risks, both inherent and unforeseeable, attached to all of the activities that I may participate in, including but not limited to waterfront activities and the high and low ropes course programs. These activities and events may cause sickness, minor injury, serious injury, or even death. I also expressly acknowledge and agree that, even with safeguards in place, Our Lady of the Fields Camp and Retreat Center cannot guarantee that I will not incur any sickness, minor injury, serious injury or even death. PUBLICITY WAIVER I give permission to Our Lady of the Fields Camp and Retreat Center to photograph and/or audio or video record me. They may use these photographs and/or recordings for educational, professional, and publicity purposes for Our Lady of the Fields Camp and Retreat Center and its Community Partners. ASSUMPTION OF RISK AND WAIVER OF LIABILITY In order to consent to participate in any and all activities and events, I expressly agree to assume all risks. Furthermore, I expressly waive, release, discharge and hold harmless Our Lady of the Fields Camp and Retreat Center, The Chaldean Catholic Church of the United States of America, its directors, officers, agents, employees, assigns, and any volunteers (altogether referred to as “Camp Parties”), from and against all liability for loss or damage of property or money, any sickness, injury (minor or serious) or death that I may incur, or any claim of any kind, however caused, resulting from or related in any way to my participation in any and all activities and events at Our Lady of the Fields Camp and Retreat Center. INDEMNIFICATION I expressly agree to indemnify and hold harmless Our Lady of the Fields Camp and Retreat Center and all the Camp Parties from any liability to me or any third party, resulting from or in any way relating to my participation and/or participation in any and all activities and events. AGREEMENT NOT TO SUE I expressly agree not to sue Our Lady of the Fields Camp and Retreat Center and all the Camp Parties for any claim, present or future, that I may have on my behalf, that may result from or in any way be connected to, my participation in any and all activities and events. COVID-19 By signing this agreement form, I acknowledging that there is an inherent risk of exposure to COVID-19 in any public place where people are present. By attending Our Lady of the Fields Camp and Retreat Center, I voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Our Lady of the Fields Camp and Retreat Center; or any of their affiliates, directors, officers, employees, agents, contractors, or volunteers liable for any illness or injury. SEVERABILITY I expressly agree that the above-mentioned Assumption of Risk, Waiver of Liability and Agreement Not to Sue are intended to be as general and wide-ranging as is allowed by the laws of the State of Michigan. If any provision of this agreement or any part of any provision of this agreement is held invalid, illegal or unenforceable under Michigan law, the remaining parts and/or provisions shall not be affected or impaired in any way. I understand the terms and conditions of this agreement. I acknowledge and agree that this agreement is binding upon my heirs and assigns. I expressly and voluntarily agree to all terms and conditions contained in this agreement. By signing below, I verify that I have thoroughly read all the contents of this agreement and hereby agree to all of the terms and conditions stated above.