Name *

First Name

Last Name

Phone *

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

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If yes, what areas are you open to supporting

Set-up/Check-in

Clean-Up

Floater (During Retreat)

Community Agreement *

Please review and agree: This retreat is a community care space. By registering, you agree to uphold respect, confidentiality, and kindness toward others.

I accept

Photography & Historical Documentation *

We will not be taking photos or videos for public use, social media, or promotional purposes. However, for historical documentation, limited photos may be taken and kept privately by United by Culture Media. These will not be shared publicly. To honor the moment, we will also provide Polaroid cameras so you can capture personal memories and stay present during the retreat. These Polaroids are yours to keep.

I understand and agree to the photography and historical documentation policy.

Liability Waiver *

By registering for this retreat, I acknowledge and agree to the following: I understand that participation in the Together We Heal Retreat involves voluntary activities that may carry certain risks. I release and hold harmless United by Culture Media (UBCM), the Stuhr Museum of the Prairie Pioneer, Miguel Estevez, and all affiliated staff, volunteers, and facilitators from any and all liability for personal injury, illness, loss, or damage to personal property that may occur during or as a result of my participation. I agree to take personal responsibility for my well-being and to follow the guidelines shared by retreat organizers.

I have read and agree to the Liability Waiver

Confirmation *

Registrations will be reviewed and confirmed via email. Do you understand that registration is not final until you receive confirmation?

Yes

No