Rescue Re-Enrollment Form
Meet with a Regeneration team member
Rescue Re-Enrollment Form
Thank you for applying to participate in a program hosted by Regeneration. Our hope and intent is that you find what you are looking for: healing, freedom, emotional or relational health, greater capacity to love well, deeper intimacy with God, or any number of other positive results.
This application will allow us to serve you better. All of the questions here are optional, and some might not apply to you (please write “N/A”). However, your honesty and openness are major factors in how much you get out of our programs. We are available any time to answer questions you might have about participation. Your responses below will be kept confidential in accordance with our confidentiality policy. Every participant is required to sign our confidentiality policy before his or her participation in any Regeneration program.
Which location are you applying for?
Maryland Rescue - Fee: $260 (Deposit $80)
Northern Virginia SALT - Fee: $300 (Deposit $125)
Rescue only: I am applying for:
Fall (Oct.- Dec.)
Winter (Jan. - Mar.)
Spring (Apr. - June)
Summer (July - Sept.)
I will submit my payments by check or online.
Please charge the deposit/initial payment, of my payment plan*, to my credit card.
Please also automatically charge, the additional payments of my payment plan*, to my credit card.
If you are paying now, please go to our Donate page and the program you are attending in the Notes field. Then simply donate the amount due.
Go there by clicking
CONFIDENTIALITY AGREEMENT AND RELEASE FROM LIABILITY
The Regeneration leadership will hold as confidential all disclosures made by clients and group participants with the following exceptions:
Disclosures indicating intentions to take harmful, dangerous, or criminal action against oneself, or another human being.
Disclosures indicating past or present acts of child abuse (physical or sexual).
Suspected acts of child abuse or neglect.
When a Regeneration leader or team member feels he/she needs advice about how to best serve participants. All such disclosures will retain anonymity as much as possible. Those informed may include one or more of the following: • Law enforcement officials and/or child protective services; • Any person likely to suffer the results of the harmful behavior indicated; • Family members of the person likely to suffer results of harmful behavior; • Family members of the person intending to harm self or other(s); • Associates and/or friends of those threatened or making threats.
I acknowledge that I have voluntarily come to Regeneration, a Christian discipleship ministry offering help and support to men and women seeking to grow in Christian purity, holiness, and maturity according to traditional biblical teachings about sex, sexuality, family and relationships.
I acknowledge that my participation with Regeneration is not a substitute for active involvement in a local Christian church of my choice.
I also acknowledge that my participation with Regeneration is not a substitute for psychiatric treatment, psychotherapy, therapeutic counseling or any other form of professional therapy. I understand that Regeneration does not offer professional therapy. Regeneration staff and volunteer team members are not licensed professional therapists. I acknowledge that if any team member possesses a professional license as a therapist, they do not serve in that capacity with Regeneration.
I accept complete responsibility for my own psychological, mental, emotional, and spiritual well being. And I further acknowledge that it is my responsibility to ascertain my own need for professional counseling and to seek such professional counseling as needed.
I understand Regeneration promotes an orthodox, biblical perspective on sex, gender, and marriage, and while the ministry respects individuals’ freedom to choose for themselves what they believe and how they will live, sometimes individuals’ perspectives can conflict or confuse the goals of Regeneration’s groups. Therefore, Regeneration reserves the right to decide on a case by case basis whether an individual can participate with Regeneration.
I understand that because my participation is completely voluntary, I have the right to discontinue my involvement with Regeneration at any time with or without prior notice.
On behalf of myself and my assigns, I waive all actions, claims or demands against Regeneration (including all agents, employees, officers, or directors of Regeneration) from any liability for any injuries suffered by me during my voluntary participation in any Regeneration service, including those resulting from negligent acts or omissions, or resulting from negligent acts or omissions of any other participant of Regeneration’s programs or groups. On behalf of myself and my assigns, I hereby agree that I will not make any claim against, sue, or otherwise seek damages against Regeneration, including those listed above.
I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Regeneration, and I sign this agreement of my own free will.
Initial Here To Confirm You Have Read And Understand The Confidentiality Agreement
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