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Centurion Project Retreat 2018!
The Centurion Project Retreat is scheduled for 12-15 March at Rolling Hills Retreat Center- Calera, Alabama 35040
*Sign-in begins promptly at 12:00pm on Monday March 12th and concludes on Thursday March 15th at 12:00pm.
There is NO COST to attendees. (All lodging accommodations and meals are included)
*The only requirement for attendees is accountability for transportation to and from the location.
Space is limited. Please do not make travel plans until you receive confirmation that your registration has been accepted
**PLEASE NOTE:
We collect demographic information, some of which is sensitive in nature for the purpose of facilitating inner healing. This information will ONLY be shared with Centurion Project Facilitator and will NOT be released to third parties.
Title
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Name
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First
MI
Last
Email
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Phone
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Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
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Barbados
Belize
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Cayman Islands
Cook Islands
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El Salvador
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Honduras
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Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
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Peru
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Armenia
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Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
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Spain
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India
Indonesia
Iran
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Israel
Japan
Jordan
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North Korea
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Kuwait
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Laos
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Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
EMERGENCY CONTACT
Please supply the Name and Relationship
(Spouse, Brother, Friend etc.)
And Emergency Contact cell phone number
*
Do you have any Food Allergies? If so explain.
Do you have any Special Needs?
Your Age
Religious Preference
Number of Marriages
Current Marital Status
Please select
Single
Married
Divorced
Re-Married
Widowed
Ages of Children
Are Your Parents- Living or Deceased?
Were Your Parents Divorced during your Childhood?
Please select
Yes
No
Are you attending with your Spouse?
Please select
Yes
No
Spouse's FIRST & LAST name
Service Status:
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Active Duty
Reserve
National Guard
Medically Separated Veteran
Retired
Law Enforcement
Emergency Medical Services
Fire Fighter
Other
If you have written "Other", please explain.
Branch of Service:
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U.S. Army
U.S. Navy
Marine Corps
U.S. Air Force
U.S. Coast Guard
Canadian Armed Forces
DOD Civilian Service
Local or Municipal Service
State Public Service
Federal Public Service
Other
Conflict or Era Served
Please select
World War II
Korean War
Vietnam
Cold War Operations
Grenada
Panama
Operation Desert Storm
OIF/OEF
Military Operations
Law Enforcement Operations
Federal or State Operations
Number of Combat Deployments
Number of deployments which included traumatic events?
What do you hope to achieve by participating in this program?
Fire Fighters and Law Enforcement or EMS
Number of Operations with Significant Trauma
Home Parish or Church
How did you hear about the Centurion Project Retreat?
*If you are on Medication or under the Care of a Counselor, Psychologist, Psychiatric Doctor, or other Mental Health Professional, are you willing to get permission from them to participate in the Centurion Project AND continue your medications and treatment until a medical professional tells you otherwise?
Please select
YES
NO
Are you willing to talk with a Centurion Project Facilitator if for any reason you feel or think you cannot complete the workshop?
Please select
YES
NO
WAIVER, RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT
In consideration for participating in the Centurion Project retreat, you, and/or your agents or family members, voluntarily assume full responsibility for and hereby release, waive, discharge, hold harmless, and covenant not to sue the Jurisdiction of the Armed Forces and Chaplaincy, or its officers, members, agents, employees, volunteers, guides and others partnering with the Jurisdiction of the Armed Forces and Chaplaincy, collectively or individually (herein, the “company”) for any and all claims, demands, actions, causes of action, and/or losses (including but not limited to any exemplary, direct, indirect, incidental, special, consequential, punitive, or other damages, medical expenses, lost wages/ income, loss of services, lost profits, property damage, pain, illness, and death) (collectively “Liabilities”) whatsoever arising out of or in any way related to your participation in this retreat and/or any activities conducted in connection therewith, regardless of whether such liabilities are caused by the negligence of any company party or otherwise, and regardless of whether such liability arises in tort, contract, strict liability, or otherwise, even if any company party has been advised of the possibility os such liabilities, the the fullest extent allowed by applicable law.
*
Please select
Yes, I Agree
NO
