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Transformational Justice Retreat 2023
Prefix
Name
(Required)
First
Last
Pronouns
Email
(Required)
Phone
(Required)
Gamaliel Affiliate Name
(Required)
Emergency Contact
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Emergency Contact Email
(Required)
Rooming
Preferred Roomate
Dietary and Accessibility
Dietary Instructions or restrictions
Please include any dietary instructions, such as allergies.
Accessibility instructions/requests
Travel
How will you travel (e.g., travel plans, car, flight, train) and when do you plan to arrive?
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Photo Release
Consent
(Required)
I agree to the photo release
I hereby grant permission to Gamaliel and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Gamaliel and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or presentation, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation A acknowledge that I am over 18 years of age.
Signature
(Required)
Payment
Double Occupancy Room
(Required)
Price:
Payment Options
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Pay Now
Pay Later
Billing Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Credit Card
(Required)
Card Details
Cardholder Name
