HoliDate Night

Join Growing Your Marriage leaders John & Lorie Weires for a one night workshop and meal where couples can intentionally work on their relationships and grow closer to God. This event will be held at Southeast Christian Church’s Blankenbaker Campus from 6:15 to 7:45 p.m. on Thursday, November 19th and will be capped at 11 couples in order to provide a more intimate space for participants to open up and share. Please complete the form below to register for this free event. PLEASE NOTE: Childcare will be available for this event. Those who need childcare will need to complete registration with Southeast Christian Church separately. You will receive a confirmation email with instructions on how to register your child(ren). Childcare is provided by Southeast Christian Church, and food will not be provided for children attending childcare.

HoliDate Night

• Your Name*
  First Last
• Your Spouse's Name*
  First Last
• Phone*
• Email*
• Spouse's Email
• Would you like to receive email updates from Barren Heights?*
  please selectYes, emails concerning guest family opportunitiesYes, emails concerning volunteer opportunitiesYes, emails concerning all opportunities!No, thank youI already receive your email updates
• Hold Harmless Agreement*
  Please check if you agree with the following statements:
  I give my consent that the information given at registration may be communicated with Barren Heights Christian Retreat Center, Inc. (Barren Heights) leaders and volunteers for the purpose of being equipped to provide the best care and assistance possible to my family.
  
  I give my consent that photographs, interviews, and audio/visual recordings taken during the event may be used by Barren Heights for training, promotion, and fundraising.
  
  I release Barren Heights, its directors, volunteers, and the event host facility from all actions, damages, or personal injuries which may occur to me or a member of my family. I understand that in the event of a minor injury, I, or a member of my family may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If the leaders are unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.
  
  I understand that in order for everyone to experience a sense of calm, peaceful relaxation, the event host facility is an alcohol, drug, and smoke-free environment. Use of cell phones is discouraged except when necessary.
  
  By checking this and the above statements and submitting this registration form, I hereby agree to this hold harmless form and all its contents. I waive on behalf of myself, my heirs, and any personal representatives all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss. I understand that this release discharges Barren Heights and the event host facility from any liability or claim that I, my heirs, or any personal representatives may have against them with respect to any bodily injury, illness, death, negligence, medical treatment, or property damage that may arise from, or in connection to any services rendered. This liability waiver and release extends to Barren Heights and the event host facility together with all owners, partners, volunteers, and employees.

• Childcare Section

• Do you have a child with a disability?*
  YesNo
• Thank you for your interest in HoliDate Night. However, this particular event is for couples who have a child with a physical and/or developmental disabilities.
• Will you be utilizing the childcare provided by Southeast Christian Church for this event?*
  Please selectYes, general childcare (ages birth–5th grade)Yes, Shine Disabilities Ministry childcare (all ages)Yes, both general (ages birth –5th grade) & Shine Disabiltiies Ministry (all ages) childcareNo, our children will not be with us
• PLEASE NOTE: Those who need childcare will need to complete registration with Southeast Christian Church separately. You will receive a confirmation email with instructions on how to register your child(ren).
• How many children in total will be utilizing childcare?*
  Please select123456

• Child One

• Child One Name*
  First Last
• Child One Birthdate*
• Which type of childcare will Child One need?*
  General childcareShine Disabilities Ministry childcare

• Child Two

• Child Two Name*
  First Last
• Child Two Birthdate*
• Which type of childcare will Child Two need?*
  General childcareShine Disabilities Ministry childcare

• Child Three

• Child Three Name*
  First Last
• Child Three Birthdate*
• Which type of childcare will Child Three need?*
  General childcareShine Disabilities Ministry childcare

• Child Four

• Child Four Name*
  First Last
• Child Four Birthdate*
• Which type of childcare will Child Four need?*
  General childcareShine Disabilities Ministry childcare

• Child Five

• Child Five Name*
  First Last
• Child Five Birthdate*
• Which type of childcare will Child Five need?*
  General childcareShine Disabilities Ministry childcare

• Child Six

• Child Six Name*
  First Last
• Child Six Birthdate*
• Which type of childcare will Child Six need?*
  General childcareShine Disabilities Ministry childcare

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