Preferred Weekend *

July 11-13 $350 is due upon Registration

July 18-20 $350 is due upon Registration

Participant's Name *

First Name

Last Name

Date of Birth *

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Participant's Cell *

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Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Cell *

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Parent/Guardian Home Phone (if different from cell)

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PARTICIPANT GUIDELINES: The following guidelines are intended to insure the safety and success of the retreat for all participants. Please read these agreements very carefully; you will be asked to reaffirm your commitment to these agreements on opening day. *

1. I agree to be respectful to all other retreat participants, staff, and retreat facility property. 2. I agree to complete confidentiality of other participants' shared experiences. 3. I agree to participate in retreat activities and remain open minded to new experiences. 4. I agree not to use or possess drugs or alcohol. I understand that smoking is not permitted unless authorized by a parent's prior written consent, and that staff will maintain possession of such, and will arrange for supervised smoking periods. 5. I agree not to possess any weapons or engage in acts of violence. 6. I agree to remain on the premises of the retreat facility at all times. 7. I understand that violation of any of these agreements will result in immediate dismissal from this program.

I have read and agree to comply with all of the guidelines.

PARENT AUTHORIZATION *

1. The person herein described has permission to engage in all retreat activities except as noted by myself or a physician. 2. In the event of an emergency I hereby give permission for the hospital selected by the facilitator to order x-rays, routine tests, and emergency treatment for the health of my child. In the event that I cannot be reached in an emergency, I hereby give permission for the hospital to secure proper treatment injections and/or anesthesia and/or surgery for my child as named above. 3. I hereby permit the release of photo/video or expressive art work of the above registered participant for the retreat promotion, training, or educational purposes. 4. I understand that full tuition for this program is due upon registration, in order to secure a space for my teenager.

I have read the written policies and agree to abide by them.

Waiver of Liability, Release Assumption of Risk, Indemnity Agreement, & Covenant Not to Sue *

It is the purpose of this agreement to exempt, waive and relieve releasee, It’s a Girl Thing Counseling Amy Frisch, LCSW, PLLC from any and all liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of release. *For and in consideration of the undersigned participant’s registration and activities in It’s A Girl Thing Weekend Retreat program, which will take place at 135 Benedict Rd. Montgomery NY 12549, on June 20-22, 2025, July 11-13, 2025 and July 18-20 2025 and being allowed to participate in this program, the participant hereby waives, releases and relinquishes any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to participant, arising out of participation in this program, whenever and however it may occur and for such period said program and activities may continue, and by this agreement any such claims, rights, and causes of action that participant may have are hereby waived, released and relinquished, and participant also does so on behalf of my participant’s heirs, executors, administrators and assigns. *Participant acknowledges, understands and assumes all risks relating to participation in this program and any damages which may arise there from and that I have full knowledge of said risks. These risks may be caused by the negligence of the participant or the negligence of others, including the releasee identified herein and above. I further acknowledge that there may be risks and dangers not known to me or not reasonably foreseeable at this time. I acknowledge, understand and agree that all of the risks and dangers that exist as result of participation in this event, which may or may not have been described in this agreement, including those caused by the negligence of releasee, participant, and others, are included in the waiver, release and relinquishment described in the preceding paragraph. *The agreement is governed and controlled by applicable law of New York. If any part of this agreement is rendered unenforceable le, all other parts shall be given full force and effect and the remainder of this agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. I further agree that any dispute arising out of this agreement and/or from my participation in this program by the undersigned shall be litigated exclusively in the Courts of the State of New York, Orange County, which shall have exclusive jurisdiction over every part in connection with any such dispute, controversy, cause of action, lawsuit or claim. *Participant agrees if any claim for personal injury, property damage or wrongful death is commenced against releasee, he/she shall defend, indemnify and save harmless releasee from any and all claims or causes of action by whomever or wherever made or presented and that participant shall not sue releasee for personal injuries, property damage or wrongful death. *Participant acknowledges that she/he has read and fully understands the above paragraphs, and that participant accepts and freely and expressly assumes all risks associated with this activity. I accept the terms and condition of this agreement. *I have made no misrepresentations to the releasee and/or herein about my name, address and other information.

I undersand and agree to all.

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card for the full cost of the RETREAT.

July 11-13 ~$350

July 18-20 ~$350

Card Holder's Name (as shown on card) *

First Name

Last Name

Card Holder's Phone *

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Participant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Participant's Cell *

(###)

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PARTICIPANT GUIDELINES: The following guidelines are intended to insure the safety and success of the retreat for all participants. Please read these agreements very carefully; you will be asked to reaffirm your commitment to these agreements on opening day. *

1. I agree to be respectful to all other retreat participants, staff, and retreat facility property. 2. I agree to complete confidentiality of other participants' shared experiences. 3. I agree to participate in retreat activities and remain open minded to new experiences. 4. I agree not to use or possess drugs or alcohol. I understand that smoking is not permitted unless authorized by retreat staff. 5. I agree not to possess any weapons or engage in acts of violence. 6 I agree to remain on the premises of the retreat facility at all times. 7. I understand that violation of any of these agreements will result in immediate dismissal from this program. 8. I hereby permit the release of photo/video or expressive artwork of the above registered participant for retreat promotion, training, or educational purposes. 9. I understand that the tuition for this program is $350, due upon registration in order to secure a space. 10. In the event of an emergency I hereby give permission to the hospital selected by the facilitator to order x-rays, recommended tests, injections, and/or anesthesia, and/or surgery, and emergency treatment for my health if medically necessary.

I have read the written policies and agree to comply with all of the guidelines .

Waiver of Liability, Release Assumption of Risk, Indemnity Agreement & Covenant Not to Sue *

It is the purpose of this agreement to exempt, waive and relieve releasee, It’s a Girl Thing Counseling Amy Frisch, LCSW, PLLC from any and all liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of release. *For and in consideration of the undersigned participant’s registration and activities in It’s A Girl Thing Weekend Retreat program, which will take place at 135 Benedict Rd. Montgomery NY 12549, on June 20-22, 2025, July 11-13, 2025 and July 18-20 2025 and being allowed to participate in this program, the participant hereby waives, releases and relinquishes any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to participant, arising out of participation in this program, whenever and however it may occur and for such period said program and activities may continue, and by this agreement any such claims, rights, and causes of action that participant may have are hereby waived, released and relinquished, and participant also does so on behalf of my participant’s heirs, executors, administrators and assigns. *Participant acknowledges, understands and assumes all risks relating to participation in this program and any damages which may arise there from and that I have full knowledge of said risks. These risks may be caused by the negligence of the participant or the negligence of others, including the releasee identified herein and above. I further acknowledge that there may be risks and dangers not known to me or not reasonably foreseeable at this time. I acknowledge, understand and agree that all of the risks and dangers that exist as result of participation in this event, which may or may not have been described in this agreement, including those caused by the negligence of releasee, participant, and others, are included in the waiver, release and relinquishment described in the preceding paragraph. *The agreement is governed and controlled by applicable law of New York. If any part of this agreement is rendered unenforceable le, all other parts shall be given full force and effect and the remainder of this agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. I further agree that any dispute arising out of this agreement and/or from my participation in this program by the undersigned shall be litigated exclusively in the Courts of the State of New York, Orange County, which shall have exclusive jurisdiction over every part in connection with any such dispute, controversy, cause of action, lawsuit or claim. *Participant agrees if any claim for personal injury, property damage or wrongful death is commenced against releasee, he/she shall defend, indemnify and save harmless releasee from any and all claims or causes of action by whomever or wherever made or presented and that participant shall not sue releasee for personal injuries, property damage or wrongful death. *Participant acknowledges that she/he has read and fully understands the above paragraphs, and that participant accepts and freely and expressly assumes all risks associated with this activity. I accept the terms and condition of this agreement. *I have made no misrepresentations to the releasee and/or herein about my name, address and other information.

I understand and agree to all.

Credit Card Authorization *

I authorize IGT to charge my credit card for the full cost of the RETREAT.

Card Holder's Phone *

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Name *

First Name

Last Name

Phone *

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I understand that by submitting my scholarship application, I may be selected to receive a $50 waiver form retreat tuition. The rest of the fee will be my responsibility, paid in full, before the time of the retreat. *

Yes, I agree.

I understand that submission of my application is not a guarantee of scholarship and I will be notified if I am selected. *

Yes, I agree.

I understand that pieces and parts of my application may be used on social media, or for advertising purposes, with the exception of any personally identifying information. *

Yes, I agree.

Everything that I have written is accurate to my best knowledge. *

Yes, I agree.

Date *

Must be completed by June 15, 2024.

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