Together We Heal Retreat: Informed Consent & Liability Waiver

Part One: Informed Consent

Overview

The Together We Heal Retreat is an in-person, invitation-only retreat hosted by United by Culture Media ("UBCM"), a nonprofit organization located at 14301 FNB Parkway, Ste. 100, Omaha, NE 68154. The retreat takes place Saturday, October 24, 2026, at Stuhr Museum of the Prairie Pioneer in Grand Island, Nebraska. Sessions are facilitated by Miguel Estevez Jr., LIMHP, LPC, NCC, and Leslie Priscilla, certified parent coach and founder of Latinx Parenting. Yoga is led by Carolina Fernandez.

Participants must be adults 18 years of age or older who are invited participants or their registered guests.

Consent to Participate

I voluntarily choose to participate in the Together We Heal Retreat hosted by UBCM. I understand that the retreat format, schedule, and facilitators may change at UBCM's discretion based on participant needs or other circumstances.

I understand that the Together We Heal Retreat is a peer support and wellness space and is not a substitute for individual therapy, medical treatment, or crisis intervention. I understand that my participation does not establish an individual therapist-client relationship with Miguel Estevez Jr., Leslie Priscilla, or any facilitator.

I understand that my participation is entirely voluntary. I may skip any activity, step away, or leave the retreat at any time, for any reason, without penalty or obligation to explain my decision. If I leave the retreat early, I agree to let a facilitator or UBCM know before I go.

Facilitator Disclosure

Miguel Estevez Jr. is a Licensed Independent Mental Health Practitioner (LIMHP) in Nebraska, a Licensed Professional Counselor (LPC) in Colorado, and a National Certified Counselor (NCC). He facilitates the retreat in a group support capacity, not as a treating clinician.

Leslie Priscilla is a certified parent coach and the founder of Latinx Parenting. She facilitates the retreat in a coaching and group education capacity, not as a treating clinician.

Carolina Fernandez leads the retreat's yoga session in an instructional capacity, not as a medical or health care provider.

Questions or concerns about Miguel's clinical licensure may be directed to the Nebraska DHHS Division of Public Health, Licensure Unit, at (402) 471-4905, or dhhs.ne.gov/licensure.

Participant Expectations & Code of Conduct

All participants agree to:

  • Treat others with respect and contribute to a safe, inclusive environment.

  • Maintain the confidentiality of anything shared by other participants.

  • Refrain from recording or photographing sessions without the explicit consent of the group.

  • Follow instructions provided by UBCM and the facilitators.

  • Respect Stuhr Museum's grounds, exhibits, and staff.

  • Refrain from disruptive or inappropriate behavior.

UBCM reserves the right to ask any participant to leave the retreat for behavior that violates these expectations or poses a risk to others.

UBCM will not record the group sessions. Any photos, video, or audio taken by UBCM will follow each participant's media consent selection on the registration form.

Venue & Privacy Acknowledgment

I understand that the retreat takes place at Stuhr Museum of the Prairie Pioneer, which is reserved for the retreat. Museum staff, caterers, and volunteers may be present during the day. While UBCM and the facilitators will make reasonable efforts to support privacy during sessions, I understand that conversations may be overheard by others working at the event.

I am responsible for choosing what I share with that in mind, to protect my own confidentiality and that of other participants.

Mental Health Authorization

I authorize UBCM to contact my designated emergency contact if a facilitator has a good-faith concern for my immediate safety or well-being during or following the retreat.

I understand that UBCM and its facilitators are not a substitute for emergency services. In a life-threatening emergency, I will contact 911 directly. If I am experiencing a mental health crisis, I understand facilitators may share crisis resources with me, such as the 988 Suicide & Crisis Lifeline, and, if appropriate, contact my emergency contact.

Confidentiality

UBCM and the facilitators agree to keep what is shared during retreat sessions confidential, except where disclosure is required by law. This includes mandatory reporting obligations for suspected abuse or neglect of a child or vulnerable adult, and situations involving imminent risk of harm to self or others.

I agree to keep confidential anything shared by other participants, and not to disclose other participants' identities, stories, or shared information outside the retreat without their explicit consent.

I understand that while all participants agree to this confidentiality expectation, UBCM cannot guarantee that other participants will maintain it. Complete confidentiality cannot be guaranteed in any group setting, and I agree to do my part to protect it.

Part Two: Waiver & Release of Liability

Acknowledgment of Risk & Waiver of Liability

I understand that participation in the Together We Heal Retreat may involve inherent risks, including but not limited to: emotional or psychological discomfort arising from discussion of personal or sensitive topics; physical activity, including yoga; walking on museum grounds and using stairs; conditions of the venue; food and beverages; volunteer tasks, if I choose to help, such as setup, cleanup, lifting, and loading; travel to and from the retreat; and interactions with other participants.

I understand that yoga is optional. I am responsible for knowing my own physical limits, modifying or skipping any pose, and consulting a health care provider beforehand if I have any concerns about participating.

Meals are provided by a third-party caterer. I am responsible for sharing any dietary needs or allergies on my registration form and for making my own decisions about what I eat and drink.

UBCM does not arrange or provide transportation to, from, or during the retreat. Participants are responsible for their own transportation. Any ride shared between individuals, including volunteers, facilitators, or other participants, is a private arrangement between those individuals. UBCM does not own, operate, or insure any vehicle used and does not provide coverage for any injury, loss, or damage related to transportation.

I voluntarily assume all risks associated with participation.

To the fullest extent permitted by law, I agree to release, waive, and hold harmless UBCM; Latinx Parenting and Leslie Priscilla; Carolina Fernandez; Stuhr Museum of the Prairie Pioneer; and their directors, officers, employees, volunteers, contractors, agents, and representatives (including facilitators), from any and all claims, liabilities, damages, or causes of action arising out of or related to my participation in the Together We Heal Retreat, including transportation, except to the extent caused by gross negligence or willful misconduct.

I understand this waiver is intended to be as broad as permitted by applicable law and does not waive rights that cannot legally be waived.

Governing Law & Severability

This agreement is governed by the laws of the State of Nebraska.

If any provision of this waiver is found to be unenforceable or invalid, that provision will be limited or removed to the minimum extent necessary, and the remaining provisions will remain in full force and effect.

Electronic Signature

By checking the acknowledgment box and typing your name in the registration form, you are providing your electronic signature. This electronic signature carries the same legal effect as a handwritten signature.