THE SHELTERGLEN MINISTRIES RETREAT

Visitor Information and Agreement Form

Guest’s Name __________________________________

Home Address _____________________________________

City ___________________________ State____________

Zip Code ___________  Phone (___)_________________

E-mail ____________________ Cell (___)____________

Date(s) you are requesting to stay at Shelterglen ___________________________  

Age ____          Marital Status:  qMarried      qDivorced      qNever Married

Social Security number or Driver’s license number: _________________________

When did you accept Christ as your savior (date) ___________________________

Are you an ordained minister ?   qyes   qno

What church or denomination ordained you? _____________________________

Are you a licensed preacher/minister?    qyes    qno

What church or denomination licensed you to preach? ______________________

Date of ordination and/or licensing ______________________________________

What denominational affiliation are you currently with? ______________________

Are your credentials in good standing?    qyes    qno

If “no” please explain : _______________________________________________

If married please give spouse’s name____________________________________

Will your spouse be with you during your stay at Shelterglen?    qyes   qno

Is your spouse an ordained or licensed minister? qyes   qno

Do you or your spouse have any special physical or emotional needs which could affect your stay at Shelterglen? qyes     qno

Explain ______________________________________________________________________________

Do you or your spouse adhere to any special dietary requirements or regiments? qyes     qno

Explain_______________________________________________________________________________

Are you or your spouse on any medications that could cause severe side effects, or affect you during your stay at Shelterglen? qyes     qno

Explain_______________________________________________________________________________

Do you or you spouse have any allergies that may affect your health or comfort during your stay at Shelterglen? qyes     qno

Explain_______________________________________________________________________________

Are you able to negotiate stairs comfortably and without assistance?    qyes     qno

Are you covered with medical/health insurance?    qyes   qno

Health insurance provider’s name : ________________________________________________________

In the case of an emergency, who should be contacted on your behalf?

Name _____________________________________________

Address __________________________________________

City ___________________________ State____________

Zip Code ___________  Phone (___)_________________

E-mail ____________________ Cell (___)____________

Policy Statement

SHELTERGLEN MINISTRIES hereby accepts no responsibility for any guest/visitor‘s actions which may cause injury to themselves or any other guest/visitor at Shelterglen. Shelterglen Ministries does not accept responsibility for the actions or statements of any quest/visitor which may cause damage to any other guest’s/visitor’s property or physical, mental or spiritual well being before, during or after their stay at Shelterglen. All visitors understand that they reside, and dine under their own advisement and at their own risk. All visitors are required to know and to understand that Shelterglen Ministries Retreat is not handicap accessible anymore than a typical private residence would be. There are stairs and other typical obstacles that are found in any private residence. Use of exercise equipment, hot tub and hiking trails on the property by guests/visitors is at the guest’s/visitor’s own risk. All visitors/quests must be 18 years of age or older. No minor children are permitted to be guests/visitors at Shelterglen. Smoking, the consumption of any alcoholic beverages or the use of any non prescribed drug or medication or contraband is strictly prohibited anywhere by anyone on the Shelterglen property. Pornography or any format of immoral or sexually inappropriate material, hate group symbols or cultic or occult literature, symbols or related activities will not be permitted on the Shelterglen property. Any violations of the above restrictions will be grounds for immediate dismissal (without reimbursement) from the Shelterglen property. Illegal conduct will be reported promptly to local law enforcement agencies.

Suggested Donations

Shelterglen ministries does not require a set fee/gift/donation for using our facilities however your donations are appreciated greatly and will help us perpetuate this ministry for pastors and Christian workers who may need it.. Corporate uses, larger church staff retreats and other such group retreats not initiated by Shelterglen Ministries should call us for price quotes for the meals and other amenities that would be required at such events.

Acceptance by the Guest

I have read this agreement and understand the conditions by which I will lodge and dine at Shelterglen Ministries Retreat. I agree to abide by the terms and conditions set forth in this agreement and hold Shelterglen Ministries Retreat, their staff, agents and representatives harmless and free of any and all liability on my behalf.    

______________________________________________       _______________

Guest’s/Visitor’s Signature                                                                                                                             Date

______________________________________________      

Guest’s/Visitor’s Printed Name

FOR OFFICE USE ONLY:

Date Received: ________________

Action Taken: _________________

Notified : _____________________

Date(s) of Visit : _______________

By: __________________________