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Handicapped Encounter Christ in New York

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By Phone and Fax

HEC Phone Number: (914) 734-2933
HEC Fax: (914) 736-6237
Application for a Retreat

Application:  Handicapped Encounter Christ                        Effective 2/22/05

2455 Hunterbrook Road

Yorktown Heights, New York 10598       (914) 734-2933  (new telephone)

Make Checks Payable to NY HEC ______________________________________________________________________

Today's Date__________ Retreat  Desired__Feb.__May__Sept___November.


Address: (Street)_______________________________________________________


Home Phone: (Area)______(Number)____________

Date of Birth_________Sex___

Age:________Approximate Weight _______ Occupation______________________

Nature of Physical Difference __________________________________________

Need Help With:                      Other Special Needs:

            ___Dressing                 ___Medications (Include list of all medications on back)

            ___Eating                     ___Wheelchair bound___Have my own.

            ___Bathroom               ___ Can Transfer ___Can not transfer alone.

            ___Walking ___Walker           ___Incontinent___Bowels ____Bladder

            ___Communication Skills          (Please supply your own pads, adult diapers, or chux)

                        __Difficulty Talking __Yes __No

                        __Devices _____________________________

                        __Sign  __Hearing problem


            1. If you play a transportable instrument, please bring it.

            2. Bring Recreation clothing, personal toiletries (Washcloth, soap, deodorant, etc.

            3. Please leave work, school work, radios, TV's etc. at home.

            4. In a short letter to accompany this application, please tell us a little about your-

               self utilizing such topics as:

                        a. What it means for me to be a Christian

                        b. What are my plans for the future

                        c. What are problems facing disabled adults today?

                        d. Other information

Fee: In order to cover the expenses of the weekend our fee is $100.00 per person.  $95.00 goes directly to Mariandale Center our retreat home in Ossining, NY, $5.00 covers the cost of supplies, snacks, etc.  However, if you are unable to give the full amount, any donation, according to your income and resources will be sufficient.  As you know Handicapped Encounter Christ is a completely volunteer program. We cannot assume responsibility for medical or Behaviorial problems.  You are an adult just like any adult that uses Mariandale Center and assume all responsibilities for oneself.

In Case of emergency, please notify __________________Phone______________

Insurance # ______________________Name of Company____________________

Physician's Name___________________Phone ______________I have read and completed this application, and understand it.______________________________(signature)


* Read and sign attached sheet:



          I understand that New York HEC is the name used for a group of people who provide spiritual retreats and some services to individuals with physical differences.  New York HEC is conducting a multi-day retreat at Mariandale Retreat and Conference Center, 299 North Highland Avenue, Ossining, New York on


____________________.  I would like to be a participant in this retreat.


          I understand that there are risks of injury to me from my participation in this retreat.  The risks include, but are not limited to, transportation to, from, and at the retreat facility (if HEC volunteers or others are providing my transportation:) transfer to and from wheelchairs, beds and other facilities (if I require assistance with such activities); and in general, the risk of injury in the conduct of daily activities.


          I understand that the care givers and other individuals who will be assisting the retreat participants are not trained or certified professionals, but are volunteers who may not have full knowledge of the needs of the participants and the special skills that may be required to meet those needs.


            I understand that the facilities at the retreat property may be limited and not designed to accommodate all my specific needs.


            Understanding these matters, I would like to attend and participate in the New York HEC retreat.  In return for and as a condition of my being accepted for participation in the retreat, I agree as follows:

            1. Medications: [initial applicable paragraph.]  I am required to take medication(s)  on a regular basis.

          _____ I will be responsible for taking and administering my medication(s)

                        during the retreat.

            _____ I cannot take or administer my required medications myself.  I agree

                        that a retreat volunteer or assistant may administer or assist me with


            2. Release and Agreement Not to Sue:  I agree that I release and discharge, and that I will not bring any law suit against, New York HEC,and it’s directors or and and all volunteers assiating at the retreat; the other participants in the retreat; the owners, operators and employees of the retreat facility; the owners or operators of any vehicles used in transportation to, from and at the retreat; and any other individuals or entities assisting in any manner in the retreat from any and all injuries, claims; liabilities that arise out of or are related to my participation in the retreat.

            3. Understanding of Loss of Right to Sue:  I understand and agree that by signing this document, if I am injured in any way, or if my property is lost or damaged as a result of my participation in this retreat, I will have no right to make claim against New York HEC or any individuals or entities assisting or furnishing facilities or equipment to the retreat participants, even if one or more of those persons is negligent or otherwise at fault in causing the injury, loss or damage to me or my property.

            4. Understanding of Legal Document:  I undderstand that this is a legal document that gives up certain legal rights.  I sign this knowingly and voluntarily.  This willbind me and my family, heirs and successors.


________________                            ____________________________

(Date)                                                               (Signature)                                                                                                                                 ____________________________(Witness)



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