Road to Unity Encounter Registration Form

Check in time on Thursday is 10:00 AM in Big Rapids and ends on Sunday at 11:00 AM.

The total cost of the encounter is $899.00.

A $499.00 non-refundable deposit is required to reserve your spot. You may also choose to pay the full $899.00 at the time of registration.

The remaining balance is due 3 weeks before the encounter begins (unless other payment arrangements have been made).

Participant Details

Husband's First Name

Husband's Last Name

Husband's Birthday

Month

Day

Year

Husband's Email

Husband's Phone

Husband's Food Allergies

Husband's Shirt Size

Wife's First Name

Wife's Last Name

Wife's Birthday

Wife's Email

Wife's Phone

Wife's Food Allergies

Wife's Shirt Size

Multi-line address

Country/Region

Address

City

Zip / Postal code

Select Date You Wish to Attend Encounter

Are you being sponsored?

Wife: Have you gone on a Reflect or Heroes Reflect?

Husband: Have you gone on The Road Home (Return) or The Heroes Road Home (Heroes Return)?

What is the name of your home church?

How did you hear about us? (If friend or church, please indicate the name)

Prayer Requests

Release & Waiver

By submitting this agreement, the undersigned desires to participate in various retreats programs, events, and activities operated by Theroadmap Inc. and The Broken Wheel Ranch Ministries.

The undersigned acknowledges that participation may incur personal injury or bodily damage and that The Road Map Inc and Broken Wheel Ranch Ministries will not allow participation without releasing and holding harmless The Road.

Further the undersigned agrees to hereby release and forever discharge The Road Map Inc their officers, directors, employees, agent, volunteers, and property owners of The Broken Wheel Ranch Ministries from all actions, claims injuries damages, cost, or expenses related to any activity in which the undersigned participates.

Husband Participant

I have read, understand, and agree to the General Release Agreement Above

Full Legal Name

Participant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Wife Participant

I have read, understand, and agree to the General Release Agreement Above

Full Legal Name

Participant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Emergency Contact Name

Relationship To Emergency Contact

Emergency Contact Phone Number

Emergency Contact Email

Payment Options

Road to Unity Payment Options

Road to Unity Deposit (Non-Refundable)$499

Road to Unity Registration $899