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Countdown to Cheyenne, WY Area Camp 2021!:

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Location Information

  • Highlands Presbyterian Camp & Retreat Center
  • 1306 Business Highway 7, Allenspark, CO, 80510 US

COVID-19 QUESTIONS

In consideration of the health and safety for all of our participants:


GENERAL QUESTIONS

  • You have attended Cheyenne, WY Area Stroke Camp before.

  • You have NOT attended Cheyenne, WY Area Stroke Camp before.

Minimum $50 (NONREFUNDABLE) per person deposit is requested with this registration. Remaining balance due one month prior to the retreat -refunds are made ONLY in the case of a MEDICAL emergency!

**Because of limited spots available, please keep additional attendees (anyone in addition to a survivor and caregiver) to a minimum.

  • age 16+

  • age 5-15

  • age 4-under


BASIC INFORMATION

Our best efforts will be made to accommodate your request , however if you are concerned about having food available that you can eat, we suggest bringing snacks and/or food to supplement your diet.

(**Your name, address, phone number, email address, and stroke date will be distributed to all in attendance at camp. All other information obtained for Stroke Camp is solely used in the event of a medical emergency and will be kept secured and confidential.)





HEALTH HISTORY INFORMATION

For your convenience, we have included the health history form into this registration. You may fill it out now to save time later, print the PDF and fill it out and send it in to us (it will be included in the confirmation email), or fill it out at camp.

If you are filling it out now, please complete ALL requested information. EACH CAMP PARTICIPANT is asked to complete a health history form. This does NOT need to be completed by a doctor!

The Health History Form is required for EACH camp participant (stroke survivors, caregivers, family members, and friends). All information being collected for the Stroke Retreat is solely to be used in the event of a medical emergency. All information will be kept secured during the event and after the event all forms will be destroyed.




AGREEMENT

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF INFORMATION AND GENERAL RELEASE

I hereby authorize Retreat & Refresh Stroke Camp ("Camp") to use, publish, and/or disclose my Individual Identifiable Information ("Information") as described herein. This authorization is voluntary. No individual has coerced or forced me into signing this authorization. I am providing this authorization under my own free will. I am under no legal liability.


I understand that Camp may benefit, monetarily, non-monetarily, or otherwise, from the use of my own Information. I understand that I will not be entitled to any of said benefits and specifically release all claims to same. I understand that once Information is received by Camp, then it may be subject to re-disclosure and may no longer be protected by federal, state, or local laws. I waive any claims of violations of federal, state, or local laws which are the result of re-disclosure.


A. Individually Identifiable Information includes, but is not limited to:

  • Video or photos of me
  • Interviews of and statements by or about me (including the use of audio or video recording devise); and
  • Mentions of my medical situation and specific health information.

B. Purpose of request:

  • For publication in print, digital, or electronic media and in any forum; and
  • For inclusion on the Camp website or other promotional material.

C. Right to Revoke

I acknowledge that I have the right to revoke this authorization only in writing. Any revocation will be prospective and not retrospective.


By checking the box below, I acknowledge and affirm the statements in this authorization form.


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BILLING INFORMATION

  • Visa
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  • American Express
  • Discover
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