Montana Gay Men's Task Force

YOUNG GAY/BISEXUAL MEN'S HEALTH RETREAT REGISTRATION - April 22 - 24, 2011
(Confidentiality Ensured)

You MUST be 16 - 24 years or older to register for this retreat. If under 18, please have the following PDF signed by your parent or guardian and mailed (P.O. Box 7984, Missoula, MT 59807) or faxed (406.829.8076) to FDH prior to April 18, 2011: ParticipantAgreement.pdf

Please complete the following electronic registration form as thoroughly as possible. Make sure you hit the "submit registration" button at the bottom of the electronic registration form. DO NOT HIT ENTER. INSTEAD TAB OR CLICK TRHOUGH THE FIELDS (Hitting enter will submit your registration form prematurely). You will be contacted shortly (within 2 - 3 business days to confirm your registration. Registration deadline is April 18, 2011.

If you have any questions regarding this registration or about our Young Gay/Bisexual Men's Health Retreat, please call 406.829.8075 or email: chantz@mtgayhealth.org

Do you live in Montana?Yes No
(Our retreats are for Montana residents. However, we do allow a limited number of Out of State participants. If you are from Out of State you MUST contact FDH & Associates to register. A fee may apply)

Have you been to a FDH or GMTF sponsored retreat in the last 12 months? Yes No

First Name: Last Name:

Home/Postal Address (include apt #):

City: State: Zip Code:

Telephone: Email Address:

Date of Birth (mm/dd/yy):

Do you have any medical or dietary restrictions?
Yes No
If YES, please explain:

Emergency Contact Name: Emergency #:

When will you be arriving on Friday (time):

(The Retreat ends on Sunday, April 24th at approximately 12:00pm)

I, the undersigned, understand and agree to release the Montana Gay Men's Task Force, FDH & Associates, their members and officers, designated assistants, other attendees, and affiliated groups and persons, from any and all liability including all degrees of physical and/or mental injury, property damage, loss, or theft that may be incurred as a result of my attendance at the Young Gay/Bisexual Men's Retreat. I understand and accept that attendance is purely at my own risk. I agree to the strict no drug or alcohol rule and realize that I may be asked to leave if I violate this policy. I have filled out this form fully and completely to the best of my knowledge.

Signature (Name in all CAPS): Date (mm/dd/yy):

Other additional comments:

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This site is made possible through funding provided by the Montana Department of Public Health and Human Services (DPHHS), HIV/STD Prevention Section.