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.
Name:________________________________________________________________
Address: (Street)_______________________________________________________
City,State,Zip__________________________________________________________
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
Note:
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:
RELEASE OF LIABILITY AND AGREEMENT NOT TO SUE
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
medications.
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)
