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
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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