BACK TO MAIN

REGISTRATION FOR THE HEALTHY RELATIONSHIPS SINGLES RETREAT HAS ENDED AS OF AUGUST 15, 2007.  WE ARE UNABLE TO ACCEPT ANY ADDITIONAL REGISTRATIONS OR PAYMENT BALANCES.

registration

Important Notice:  YOU MUST PAY ONLINE AFTER COMPLETING THIS FORM 

 
First Name:   Middle Initial:
Last Name: (Include 'X' and slave name, if applicable.)
Address1: (Use address line 2 if necessary)
Address2:
City:     
State:
Zip Code:
Email:   
Day Phone:
Evening Phone:
Age and Gender: Male   Female  Age: REQUIRED
Are you currently courting someone?  Yes    No
Are you single (never married, widowed, legally documented divorced):  Yes    No
How did you learn about this Retreat?
Date/time you plan to arrive:
 Date/time you plan to depart:
Mosque # or Study Group
Mosque/Study Group, City, State
 Captain's name:
 Captain’s contact number:
 Are you in good standing in your Mosque?    Yes    No

Health Information
Do you have any special health conditions or needs that we should be aware of?
Yes    No      If Yes, please list:  
 Are you a licensed doctor, nurse, counselor, psychiatrist, or psychologist?    Yes    No
In case of emergency, contact:   
Name:
Phone:
Relation to You:
Accommodations
To ensure the comfort of others, please indicate if you snore: Yes    No
NOTE: As of July 19th, 2007, the retreat has no more Double Rooms (2 double beds) available.  Please only register for the Single Rooms (2 single beds).

Preferred Accommodations (check one) – Single rooms go to first 162 applicants
$163 - Single (2 single beds)   
Name of preferred roommate (include full name, city, state if different from yours):

(we will assign someone if you have no preference)
Activities  

Please select a Retreat Activity in which you would like to participate (assignments are made in order of registration):

Click icon for description of paid activities document
 REGISTRATION FOR PAID ACTIVITIES ENDED AS OF AUGUST 10, 2007.  WE ARE UNABLE TO ACCEPT ANY ADDITIONAL PAID ACTIVITIES REGISTRATIONS.

PAYMENT BALANCES CAN STILL BE SUBMITTED. BELOW ARE FREE ACTIVITIES THAT MAY BE SIGNED UP FOR:

Choice 1:    Choice 2:   
  Basketball
 Hiking
Relaxing
Study Circle
Tennis
Volleyball





Basketball
 Hiking
Relaxing
Study Circle
Tennis
Volleyball





Other Activities that you may participate in: 
Yoga (free).....Note: Please bring a yoga mat or a towel for yoga.

Are you physically able to participate in the Team Challenge Course?    Yes   No
Travel/Transportation

Will you need transportation to retreat facility?    Yes    No
Will you be renting a vehicle?    Yes    No
FEES

Registration fee is $25 (non-refundable)

Total Retreat fees (includes registration): Single: $188 Double: $225

Deposit: $94 due at time of registration (registrations will only be accepted if accompanied by a deposit or full Retreat fee)

All monies for optional additional activities are due no later than August 5, 2007

All unpaid retreat fees are due no later than August 5, 2007

Please send in a money order or cashiers check only to:

Healthy Relationships
2716 Ward Lake Ct.
Ellenwood, GA 30294
 DISCLAIMER, Deposit and cancellation:

As a participant of the 2007 Healthy Relationships Retreat, I agree to be solely responsible for and indemnify, defend, and hold harmless all of the staff and volunteers of the Healthy Relationships 2007 Retreat. This includes the Healthy Relationships Initiative, Inc. Staff, the entire Nation of Islam, its owners, operators, employees, officers, and agents, for all loss or damage originating from or in connection with, all activities of the Healthy Relationships 2007 Retreat, the YMCA, or any of its contractors or affiliates for all claims or demands for damages to property of for injury or for death of persons directly or indirectly resulting from such activities of whatsoever nature (except loss or damage caused by the gross negligence or wrongful act of the Healthy Relationships 2007 staff and The YMCA’s staff and both entities owners, operators, employees, or officers).

We are not responsible for any costs you incur in preparation for your retreat. In the event that you find it necessary to cancel your participation in this retreat, we must receive written notice of your cancellation by mail or email. Your refund will be determined by the date that we receive notification.

Consult the following timetable:

We receive your notification…this many days prior to retreat:

Refund:

Up to 6/15/2007

100% of retreat fee

Between 6/16/2007 and 7/15/2007

50% of retreat fee

7/16/2007 and After

No refunds

In submitting this online registration information, I am signifying that I have read and understand the registration, including:  retreat fees, lodging, registration and cancellation policy.
 

If you need immediate attention, please email: SinglesRetreat@noi.org

 
BACK TO TOP

.