Muslim Retreat- The Lodge at Woodloch

Age: 16 and older
Dates: Monday, February 28 - Wednesday, March 2nd, 2022
Checkin/Check out: 4:00 pm on Monday, February 28, 2022--12:00 pm on Wednesday, March 2, 2022
Location: The Lodge at Woodloch 109 River Birch Ln, Hawley, PA 18428
Ticket: $985 -$1,350

Your pictures are private. This is only for the Pious Hearts Team.

Headshot

Full Body

First Name:

Last Name:

Email:

Phone:

Age:

Birthday:

**Your ID will be checked at the event to confirm your age.

Gender:

Height Feet:

Height Inches:

Country:

Address Line 1:

Address Line 2:

City, State, Zip Code:

What is your ethnicity?

What is your race?

Profession:

Highest Degree:

Citizenship:

Marital Status:

Are you interested in getting married?

Yes No

Would you consider someone previously married?

Yes No

Would you consider someone divorced with kids?

Yes No

Would you marry someone from a different race than yours?

Yes No

What age range are you interested in?

Which describes your religious views?

Name 3 things you like to do in your free time?

About me - Write a few sentences to describe yourself:

Have you ever attended a Pious Hearts Event?

Yes No

Did any person or organization refer you to Pious Hearts Event?

How did you hear about us?

Are you bringing a friend or family member?

Yes No

If you are bringing anyone 21 years or older and they are not your spouse, they will need to fill out their own registration form.
List only members that are 20 years or younger or they are the spouse.

First Name

Last Name

Date of Birth

Select an option:

$ 985 - Per person, double occupancy (2 queen beds)

$ 1350 - Per person, single occupancy ( 1 king beds)

NOTICE OF FILMING AND PHOTOGRAPHY

By attending a Pious Hearts event, you are entering an area where photography, audio, and video recording may occur.

By agreeing to these terms, you consent to photography, audio recording, video recording, and its release, publication, exhibition, or reproduction to be used for promotional purposes, advertising, inclusion on websites, social media, or any other purpose by Pious Hearts and its representatives. You release Pious Hearts, its employees, and each and all persons involved from any liability connected with the taking, recording, digitizing, or publication and use of interviews, photographs, computer images, video and/or audio recordings, and you waive all rights to any claims for payment or royalties in connection with any use of these materials. You also waive any right to inspect or approve any photo, video, or audio recording taken by Pious Hearts or the person or entity designated to do so by Pious Hearts.

A person attending a Pious Hearts event who does not wish to have their image recorded for distribution should make their wishes known to the event organizers by contacting Pious Hearts at piousheartsevents@gmail.com in writing.

I agree to the notice of filming and photography

Pious Hearts, LLC and The Lodge at Woodloch CORONAVIRUS/COVID-19 WARNING, ASSUMPTION OF RISK, AND WAIVER

I hereby acknowledge that the coronavirus COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. I acknowledge that by attending the Pious Hearts Muslim Retreat at The Lodge at Woodloch or accessing any of its facilities, I could increase my risk of contracting COVID-19. I understand and agree that neither Pious Hearts nor The Lodge at Woodloch in any way warrants that COVID-19 infection will not occur through my attendance at the above event or by accessing any of its facilities. I hereby voluntarily seek to attend the above retreat event and acknowledge that my actions may increase my risk of exposure to the coronavirus COVID-19. I accept the risk and release and agree to hold harmless Pious Hearts, LLC and/or The Lodge at Woodloch, the owners, employees, team, and guests of either of them, from any and all claims that may arise from or relate to my attendance at the above event or my use of Pious Hearts, LLC and The Lodge at Woodloch, including any claims concerning exposure to the coronavirus COVID-19 and any resulting harm or injury, including permanent disability and death. I acknowledge and agree that during my attendance at the above retreat event, I will comply with all procedures designed to reduce the spread of COVID-19.*:

I acknowledge that I understand, accept, and affirm the Covid-19 waiver information in the statements above.

Payment

**Don't worry we will only charge you if you are selected to attend our event. All tickets are non-refundable

Our team will review all registered guests and choose those who applied first and qualify. Only if we select you to be a guest at our event, will your credit/debit card on file be charged. We will charge your card automatically without notifying you since your registration is your form of permission to be charged if we select you. If for any reason once you register and you decided you no longer can attend this please email us at piousheartsevents@gmail to let us know to cancel your registration before we select and charge you. Once you are selected and charged your ticket is non-refundable. You will not be charged anything if you are not picked; don’t worry we will have plenty of other events that you may be invited to attend, InshaAllah.

I agree to the notice of payment if selected

Accepted:

Card Number:

Expires:

CVC: