Love City Impact Retreats-Registration Form
Please complete this form to register for the January 12th through January 19th, 2025 trip. 
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First Name *
Last Name *
Preferred Name (if different than first name listed above)
Contact Information and Address
Street Address *
City  *
State *
Zip Code *
Primary Phone Number *
Email *
Birthdate (All participants must be 21 years of age) *
MM
/
DD
/
YYYY
Emergency Contact: Name/Relationship 
(ie. Nick/Spouse)
 *
Emergency Contact: Phone Number *
All participants must have their own health insurance if medical care is needed on the trip. Do you have medical insurance coverage? *
Allergies (foods, medications, insects bites, etc.) *
Special Considerations: Describe any physical conditions or medications that might affect your participation or safety on the trip. 
Identify any special dietary needs or requests: 
(all meals have a dairy free and gluten free option)
Hiking and trail work are a large component of the service work on the island. 
Are you able to hike 3-miles on trails while carrying a backpack?
 *
Accommodations (platform tents) will hold 1-3 participants. Are you interested in your own tent? **this is not a guarantee, we just like to know who would be interested** *
If you want to share accommodations with a specific person, enter their name(s) here:
T-shirt Size *
Do you agree with our payment and refund policy below?

Love City Impact Retreats Payment and Refund Policy:  By submitting my application and payment to participate in the Love City Impact Retreat, I acknowledge that I agree to the following Payment and Refund Policy: 

1. Full Payment for the trip is due no later than December 1st.  
2. If my application is not accepted, or the volunteer trip is full or cancelled by Love City Impact Retreats, I will receive a 100% refund.  
3. If I notify Love City Impact Retreats in writing that I wish to cancel my trip participation, I will receive a refund of the amount paid, less the following fees: 

If I cancel: 
• 91 days or more before the trip: cancelation fee is $100
• 61 – 90 days prior to the trip: cancellation fee is $400 
• 31 – 60 days before the trip: cancellation fee is 50% of the trip price-$650 
• 0 – 30 days: cancellation fee is 100% of the trip price (no refund due)

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To finalize your registration, please send deposit/payment to:

Love City Impact Retreats
1135 Tenth St. N
Hudson, WI 54016

Please select which payment option you will be choosing:
 *
You will receive email confirmation of your registration from:
info@lovecityimpactretreats.com
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