ACC IDENT WAIVER AND RELEASE OF L IABIL ITY FORM Name o f the Par t ic ipant : _____________________________________Date o f Ac t iv i t y or Event : __________________

P lease check : � Antioch Church of Long Beach 2011 Women’s Retreat at the Hyatt Grand Champions I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND/OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems, which preclude my participation in this activity or event. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said activity or event. In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: Antioch Church of Long Beach and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers; (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise. I acknowledge that the Antioch Church of Long Beach and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of the Antioch Church. I acknowledge that this activity or event may involve a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to participants, but are also present for volunteers. I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident, and/or illness during this activity or event. I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, and assigns. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. ________________________________ _________________________________ ___________________ Print Participant’s Name Signature Date

Trip to:Miramonte Resort & Spa45000 Indian Wells LnIndian Wells, CA 92210(800) 237-2926126.37 miles2 hours 16 minutes

Notes

If you need any help, please contact the Miramonte Resort at 760.341.2200 or Yvette Lawson at 562.276.8222

1535 Gundry AveLong Beach, CA 90813-2319

Miles PerSection

1. Start out going NORTH on GUNDRY AVE toward E 16TH ST. Go 0.2 Mi

2. Turn RIGHT onto E PACIFIC COAST HWY / CA-1 S. Pass through 1 roundabout. Go 3.3 Mi

3. Turn SLIGHT LEFT onto E 7TH ST / CA-22 E. Continue to follow CA-22 E.CA-22 E is 0.1 miles past ULTIMO AVE

Go 4.2 Mi

4. Keep RIGHT to take CA-22 E via EXIT 21 toward GARDEN GROVE. Go 12.5 Mi

5. Merge onto CA-55 N via the exit on the LEFT toward ANAHEIM / RIVERSIDE. Go 5.6 Mi

6. Merge onto CA-91 E. Go 31.0 Mi

7. Merge onto CA-60 E toward I-215 S / SAN DIEGO / INDIO. Go 23.3 Mi

8. Merge onto I-10 E via the exit on the LEFT. Go 40.0 Mi

9. Take the COOK STREET exit, EXIT 134. Go 0.3 Mi

10. Turn RIGHT onto COOK ST.If you reach I-10 E you've gone about 0.2 miles too far

Go 4.5 Mi

11. Turn LEFT onto CA-111.CA-111 is 0.2 miles past CACHUMA RD

Go 1.5 Mi

12. Turn RIGHT onto INDIAN WELLS LN.INDIAN WELLS LN is 0.5 miles past ELDORADO DR

Go 0.01 Mi

13. 45000 INDIAN WELLS LN is on the RIGHT.If you reach the end of INDIAN WELLS LN you've gone about 0.1 miles too far

Miramonte Resort & Spa45000 Indian Wells Ln, Indian Wells, CA 92210

126.4 mi

(800) 237-2926

Total Travel Estimate: 126.37 miles - about 2 hours 16 minutes

All rights reserved. Use subject to License/Copyright

Directions and maps are informational only. We make no warranties on the accuracy of their content, road conditions or route usability or expeditiousness.You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or delay resulting from your use of MapQuest. Your use ofMapQuest means you agree to our Terms of Use

Photograph Release Form

Permission to Use Photograph

Antioch Church of Long Beach, Thirtyone10 Women’s Ministry

I grant to Antioch Church of Long Beach, its representatives and employees the right to take photographs of me and my property in connection

with the above-identified subject. I authorize Antioch Church of Long Beach, its assigns and transferees to copyright, use and publish the same in

print and/or electronically.

I agree that Antioch Church of Long Beach may use such photographs of me with or without my name and for any lawful purpose, including for

example such purposes as publicity, illustration, advertising, and Web content.

I have read and understand the above:

Please mark an X below if you do not wish to be photographed:

_____I do not w ish to be photographed

Printed name ___________________________________________________________________

Signature __________________________________________ Date _____________________

Emergency Contact Information

Your Name:_________________________________________________________________

In the case of emergency, please contact the following individuals on my behalf:

Contac t #1

Name:___________________________________________________________________________

Phone:___________________________________________________________________________

Relationship to you:_________________________________________________________________

Contac t #2

Name:___________________________________________________________________________

Phone:___________________________________________________________________________

Relationship to you:__________________________________________________________________

To register for Retreat 2011 please submit this form with your deposit: (Please print clearly)

Name:________________________________________________________

Address:________________________________________ Apt#:__________

City:___________________________ State:______________ Zip__________

Phone:__________________________ Email:_________________________

My T-shirt size is: Small Medium Large X-Large XXL 3X 4X

I am requesting the following accommodations:

____Single $360 ____Double $270 ____Triple $250 ____Quadruple $240

I want to upgrade to: Dolce Suite______ Villa Suite_______ Price $_________________

For Thursday Only

____Single $450 ____Double $315 ____Triple $285 ____Quadruple $270

I want to upgrade to: Dolce Suite______ Villa Suite_______ Price $________________

Deposit is due at the time of registration. Entire balance must be paid in full before June 5th, 2011. Deposits are non-

refundable but are transferrable. Cancellation and refund of full payment is permitted before May 1st, 2011. Installment

plans are encouraged.

I am requesting to room with the following ladies: 1._____________________________________________

2.______________________________________ 3._______________________________________

Do you have special dietary needs or allergies?_________________________________________________

Please make all checks & money orders payable to Antioch Church and mail to:

Antioch Church

Attn: Women’s Retreat

1535 Gundry Avenue LB, CA 90813

Please place Women’s Retreat on memo line

I have read and understand the cancellation policy and I understand that I will not receive a refund for the deposit that was paid under any

circumstance. I understand that my balance must be paid in full by 6/5/11 and that if at any time I experience hardship I can alert the retreat staff for

special arrangements. Installment plans are provided as a courtesy and I understand that I must make the agreed upon payments to secure my

space and accommodations at the 2011 Annual Women’s Retreat.

Signature:_______________________________________________ Date:_______________________

IMAGINE M

E RETREAT 2011

2011  Women’s  Retreat  June  24th-­‐June  26th,  2011  

Ladies,  Our  2011  women’s  retreat  is  here.  This  will  be  an  amazing  and  unforgettable  year.  We  have  begun  our  final  preparations  and  making  arrangements  to  ensure  a  well  planned  weekend.    Our  theme  this  is  year  is  “Imagine  Me,”  Lamentations  1.  Begin  thinking  and  praying  about  what  you  expect  to  receive  at  this  year’s  retreat.    Additional  Options:  Drive  up  early  on  Thursday  for  approx  $100  per  night  per  room.    Pricing  for  this  added  feature  is  in  your  handout.  You  are  responsible  for  all  your  meals.  Use  this  time  to  unwind,  spa  treatments,  and  to  shop  at  the  outlets.  Transportation  will  be  provided  if  necessary.      Room  upgrade  to  the  Dolce  Suite.  $110  additional  dollars  per  night  per  room.    .  These  spacious  junior  suites  are  550  square  feet  and  have  a  separate  living  room  area  with  second  television,  a  full-­‐size  pull  out  sofa  and  feature  all  the  amenities  as  the  Luxury  guestrooms.  Baths  in  the  Dolce  Suite  feature  dual  separate  marble-­‐slab  vanities  and  sinks,  as  well  as  marble  tiled  showers.  All  Dolce  suites  have  a  private  oversized  patio  terrace,  with  views  of  the  citrus  and  olive  groves  and  resort  grounds.  These  rooms  have  Double  Beds  and  Sofa  Couch.    All  meals,  no  hotel  accommodations.  $185  per  person.  Fee  includes  bag,  T-­‐shirt,  all  workshop  classes,  night  sessions,  offering,  Friday  Night  dinner,  Saturday  Lunch  buffet  and  dinner,  all  taxes,  tips,  and  gratuities.      Sessions  Only  $100.  Fee  includes  bag,  T-­‐shirts,  workshops,  and  night  sessions.  

Please  Remember  the  Following...  

• If  you  have  not  paid  your  balance  please  do  so,  AS  SOON  AS  POSSIBLE  

• Please  arrive  at  Antioch  at  9:30  am  on  Friday,  June  24th,  2011    

• BUS  WILL  LEAVE  AT  10:00  am  SHARP!  

• Pack  lightly-­‐  it  will  be  warm  

• Dress  comfortably  at  for  all  sessions,  wear  whatever  you  like  

• T-­‐shirts  will  be  given  upon  arrival  and  is  to  be  worn  with  black  bottoms  on  Sunday,  June  26th,  

2011  to  the  worship  service.  

• Bring  swimsuit  (if  swimming)  and  sunscreen  

• For  room  service  and  phone  usage  please  bring  credit  card  

• Check-­‐in  is  at  3pm  (if  driving)  

• Don’t  forget  your  bible  

• Retreat  is  all-­‐inclusive  of  food,  transportation,  and  resort  accommodations.  Bring  money  

only  for  late  night  snacks  and  after  hours  dining.  

• We  will  fast  the  week  of  Sunday,  June  20th  until  Wednesday,  June  22nd,  2011  

NO  MEATS,  NO  SWEETS,  NO  TELEVISION,  ONLY  WORSHIP  MUSIC  

• Please  send  time  in  prayer  and  worship  each  day  to  prepare  for  the  weekend.  

• Expect  an  awesome  time  in  the  Lord  

• Please  review  the  weekend  schedule  and  make  the  on  Saturday  of  the  retreat  

• If  possible,  let  us  know  you  are  driving.      

• REMEMBER,  every  women  staying  at  the  hotel  receives  a  $20  spa  gift  card  toward  a  

treatment.  

• Please  make  your  spa  appointments  now  by  calling  866-­‐THE-­‐WELL    

 

WHAT  WILL  HAPPEN  ON  FRIDAY,  JUNE  24th,  2011  

• Parking  will  be  available  and  secure  throughout  the  weekend  in  our  15th  street  parking  lot.  

We  do  prefer  that  you  get  a  ride  to  the  church  or  carpool.  

• Leave  suitcase  on  the  sidewalk  immediately  in  front  of  the  church.  There  will  be  staff  

persons  watching  your  items.  If  buses  are  parked  please  put  your  bag  in  front  of  the  bus  you  

will  ride  on.  

• Go  downstairs  on  the  lower  level  of  Antioch  to  register    

• Sign  in  and  fellowship  with  other  ladies  until  the  bus  leaves  at  10:00  am  

• Please  eat  before  you  come  and  you  are  more  than  welcome  to  bring  snacks  for  your  room.  

• If  you  are  driving  you  will  pick  up  your  materials  during  the  meet  &  greet  hour  or  at  dinner.  

 

 

 

 

 

 

 

 

 

 

Pricing for 2011 Women’s Retreat

Single Double Triple Quad

Standard 360 270 250 240

Dolce 585 385 325 295

Villa 805 495 400 350

Single Double Triple Quad

Standard 450 315 285 270

Dolce 785 485 400 355

Villa 1120 655 510 435

All Inclusive Pricing for Friday, June 24th, 2011- Sunday, June 26th, 2011

All Inclusive Pricing for Thursday, June 23rd, 2011- Sunday, June 26th, 2011