Relax & Ease into Sacred Time for Rest & Healing with Healing Touch Session (October)

* These fields are required

1 Welcome

2 Price

3 Participant Info

Phone *
Address
Address 2
City
State/Prov.
Zip/Postal
Country
Email newsletter	Please send me the email newsletter
Have you previously been a guest at Well of Mercy?	Yes No This includes Day and Overnight Personal Retreats, Hosted group retreats, or Well of Mercy Sponsored (Day or Overnight) Retreats
Comments or Special Needs
Special Diet	Please note: Well of Mercy is only able to accommodate Gluten Free or Vegetarian diets when indicated. You will receive a menu prior to your retreat. Please feel free to bring additional food and drink items to supplement as needed.
Emergency Contact Info	Name and Number
Guest Agreement Terms and Conditions	By using the property, facilities and services of Well of Mercy at 118 Mercy Lane, Hamptonville, NC 27020, I acknowledge and am bound by the terms of this Acknowledgement Guest Agreement.
I agree to adhere to Well of Mercy Protocols-To follow any instructions, directions or policies Well of Mercy has established to ensure the best possible guest experience for myself and others who have also chosen to visit this sacred space. That all activities and participation at Well of Mercy are voluntary and are undertaken entirely at my own discretion. Not to use open flames, candles, incense or other flammables and understand that I am liable for any costs and damages caused by doing so.	Please Initial Here
I Assume Level of Risk- My participation at Well of Mercy may involve physical activities, use of the property, facilities and grounds (including but not limited to walking trails, use of labyrinth and other features on the land) and exposure to outdoor elements (such as sun, rain and contact with uneven surfaces, poison oak, deer ticks, insects, wildlife, etc.). I voluntarily assume the unlikely risk of any injury which may be sustained while visiting Well of Mercy facility and grounds. If stairs, gravel, or hills present a mobility challenge, please contact our office to review options. In the event that I have a medical or psychological emergency, Well of Mercy has the authority and discretion to contact 911 emergency services and/or my emergency contact. Any costs incurred for the provision of health services are my responsibility and not the responsibility of Well of Mercy. Well of Mercy does not provide professional medical and/or psychological care.	Please Initial Here
I Assume Level of Risk- I am physically and emotionally able to participate in activities I voluntarily engage in at Well of Mercy. It is my responsibility to determine my physical and mental fitness prior to my arrival at Well of Mercy and I will inform Well of Mercy staff if at any point I do not feel well during my visit. If in the opinion of Well of Mercy staff, I am unable to participate appropriately in Well of Mercy activities, I understand that I may be asked to leave the premises.	Please Initial Here
Release of Liability- By signing this form, I release Well of Mercy or any associated entity from any liability claim that I, my heirs, and my assigns may have against Well of Mercy with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Well of Mercy, or any associated entity, I am entering into this release voluntarily and at my own risk. This liability waiver and release extends to all Well of Mercy agents, employees, leaders, volunteers, officers, and board members. To the extent not prohibited by applicable law, I also agree to indemnify Well of Mercy against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of or presence at the facilities of Well of Mercy. It is my responsibility to share any concerns arising from this Agreement through friendly conversation with Well of Mercy administration.	Please Initial Here
Online Agreement- This Agreement may be signed electronically or agreed to by having me click “I Agree”, the effect of which will be the same as signing by hand and the intention of which is that both parties desire to be bound by all terms of the Agreement.	Please Initial Here

4 Donate

5 Security Check

6 Payment

	By submitting payment, you authorize Well of Mercy to send instructions to the financial institution that issued your card to take payments from your card account in accordance with the terms of Well of Mercy's agreement with you.