EPILEPSY FOUNDATION of WISCONSINADULT RETREAT APPLICATION & REGISTRATIONSEPTEMBER 26 - 28, 2025 Name * First Name Last Name Date of Birth * GENDER * MALE FEMALE PREFER NOT TO ANSWER Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email If you do not use email type "N/A" in this area EMERGENCY CONTACT #1 * Please type in the person's full name, phone number, and how they are related to you. EMERGENCY CONTACT #2 * Please type in the person's full name, phone number, and how they are related to you DISCLAMERS and LIABILITIES I understand that the adult retreat (A.R.) offers a variety of physical activities that are potentially hazardous, such as, but not limited to, the climbing tower, adventure course, nature hikes and water activities. I understand the Epilepsy Foundation of Wisconsin has taken precautions to provide supervision, instruction, and equipment for each activity, however it is impossible to guarantee safety. I consent to participate in A.R. activities. Further, I waive any claim against the Epilepsy Foundation of Wisconsin and their employees, the Wisconsin Lions Camp and their employees which may arise as a result of participation in the A.R. programs * I AGREE and UNDERSTAND I consent to the staff of Epilepsy Foundation of Wisconsin or Wisconsin Lions Camp seeking of emergency medical treatment if they deem it necessary. I agree that I am responsible for any and all medical charges and expenses resulting from treatment on or off-site. I also acknowledge that I am responsible for my own medication storage and administration * I agree and understand I further give permission for my photograph to be taken at the adult retreat. I understand that the photographs may be used for educational information and/or publicity purposes by the Epilepsy Foundation of Wisconsin, its affiliates and/or the Epilepsy Foundation of America. Photos will be available to all participants of the A.R.: * I Understand and Agree Individuals who violate limits of acceptable behavior including, but not limited to, fighting, grabbing, verbal abuse, property destruction, sexual harassment and/or stealing will be asked to leave the A.R. Weapons and illegal substances are not allowed on Wisconsin Lions Camp property and smoking is allowed in designated locations only * I Understand and Agree TYPE YOUR FULL NAME and TODAY'S DATE * This will serve as your signature for this section REGISTRATION INFORMATION *FINAL DEADLINE FOR REGISTRATION: Monday, September 8, 2025 *For Registration Questions or Questions about the retreat in general, contact John : jmirasola@epilepsywisconsin.org -OR- (608) 665-9942 COST and PAYMENT INFORMATION *The price to attend the retreat: $165 ($50 to attend ONLY on Saturday) *CASH WILL NOT BE ACCEPTED FOR PAYMENTS THIS YEAR. If you are only able to pay by cash, contact John Mirasola for instructions *If you need to pay in increments, please contact Mary Oliver *To pay by CREDIT CARD, contact Mary Oliver: moliver@epilepsywisconsin.org *To pay by CHECK, make your check payable to: "The Epilepsy Foundation of Wisconsin." *Payments must be received no later than September 19, 2025 *MAIL YOUR CHECK TO: Epilepsy Foundation of Wisconsin c/o Adult Retreat 6666 Odana Rd. #108 Madison, WI 53719 HEALTH INFORMATION I acknowledge that this information is freely, willfully given, and understand that it is used for internal staff members only * I understand and agree In the event of an emergency, I consent to my voluntary health information being relayed to emergency personnel * I Understand and agree I acknowledge that if I choose to withhold medical information, the Epilepsy Foundation of Wisconsin, its employees and Wisconsin Lions Camp, their employees and/or emergency medical staff is not held liable for mistreatment or care resulting from withheld information * I understand and agree FOR EMT / HOSPITAL STAFF First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### GENDER * Male Female Prefer not to answer BIRTH DATE and YEAR * EPILEPSY / NEUROLOGY CLINIC NAME * NEUROLOGIST NAME & PHONE No. * PRIMARY CARE DOCTOR NAME & PHONE No. * SEIZURE TYPE(S) * DESCRIBE WHAT YOUR SEIZURES LOOK LIKE * Please be specific WHAT SHOULD BE DONE FOR FIRST AID IF/WHEN YOU HAVE ANY OF THESE SEIZURES? * Please list ALL prescribed or over the counter medications, (INCLUDING DOSAGE AMOUNTS AND HOW OFTEN YOU TAKE THEM) that you are now taking on a regular basis for ANY Health Condition. * WHAT ARE YOUR KNOWN OR SUSPECTED SEIZURE TRIGGERS? (If unknown, please write "unknown") HAVE YOU EVER HAD STATUS EPILEPTICUS? * YES NO WILL YOU BE BRINGING DIASTAT, DIAZAPAM, or ANY OTHER EMERGENCY MEDICATION? * YES NO HAVE YOU HAD BRAIN SURGERY FOR YOUR EPILEPSY? * YES NO DO YOU HAVE A VNS IMPLANT? * YES NO DO YOU HAVE AN RNS IMPLANT? * YES NO DO YOU HAVE A DBS IMPLANT? YES NO DO YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS PLEASE CHECK ALL THAT APPLY Allergies Speech Impairments Diabetes Cancer Angina Migraines Cerebral Palsy Food Allergies Hearing Difficulties Asthma Bleeding Disorders Joint / Muscle Problems Thyroid Problems High Blood Pressure Other IF YOU ANSWERED "YES" DO ANY OF THESE, PLEASE GIVE US AS MANY DETAILS AS POSSIBLE ABOUT YOUR CONDITION(S) IS THERE ANY OTHER HEALTH INFORMATION YOU WOULD LIKE US TO KNOW ABOUT? TYPE YOUR FULL NAME and TODAY'S DATE * This will serve as your signature for this section DIRECTORY INFORMATION We will be printing a directory of attendees so that you may stay in contact with friends that you meet at the Adult Retreat. We will place every ones name and city or town in the directory. We would like to include addresses, phone numbers, and email. PLEASE CHECK ONE OF THE FOLLOWING: * PLEASE INCLUDE MY ADDRESS, EMAIL, and PHONE NUMBER IN THE DIRECTORY PLEASE DO NOT INCLUDE MY ADDRESS, EMAIL, and PHONE NUMBER (only your name and home town will be listed) TRANSPORTATION INFORMATION ALL RETREAT ATTENDEES MUST ARRANGE THEIR OWN TRANSPORTATION DO YOU HAVE A RIDE TO THE RETREAT? * YES NO IF YOU HAVE A RIDE, WOULD YOU BE WILLING TO BRING OTHERS? * YES NO IF YOU STILL DO NOT HAVE A RIDE, EMAIL JOHN IF YOU WISH TO BE GIVEN A LIST OF PEOPLE WHO ARE WILLING TO BRING OTHERS NOTE: This is NOT a guarantee that you will have a ride - each person will be expected to work out the arrangements on their own **Please do NOT arrive before 3:30 pm on Friday / first activity is at 4:30 pm. Lodging will not be available, and no staff will be available if there is an emergency **Departure time on Sunday is between 1:30 and 2:00 pm after lunch and the awards ceremony Thank you!
