November 6-9, 2025 Shakertown, KY $450 At this time the retreat has 0 spots remaining. This is a notice that you will be added to a waitlist if you complete the registration and we will be in contact if a spot opens up.Have questions first? Feel free to contact Jeremiah Kuhn at (859) 576-6780Personal InformationName(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Date of Birth MM slash DD slash YYYY Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Retreat InformationHow did you hear about this retreat?(Required)In a few sentences, describe your walk with God.(Required)What do you hope to receive from this event?(Required)Upload a Headshot (optional)Max. file size: 128 MB. Room Accommodations(Required)Happy to share a room/suite with private bathPrefer my own room with a private bath (+$150)Single Rooms are limited and available on a first come, first served basis.Roommate RequestHealth InformationDo you have any food allergies or dietary restrictions? If so, please describe here:Shaker Village can accommodate food allergies and dietary restrictions for all meals as long as we know before the event.Do you have any medical of physical needs that you would like us to be aware of (i.e. CPAP, high blood pressure, physical mobility, etc.)? If so, please describe here:Name for Emergency ContactPhone for Emergency ContactPayment Information$150 deposit is required with registration or you can choose to pay the full retreat amount. For this event we can accept payment through Venmo, Cash App, Zelle, or a mailed check. We are not able to accept credit cards at this time. We are able to refund any/all payments before September 30, 2025 if your plans change and you cannot attend the event.Payment Amount(Required)$150 - Deposit (Required)$450 - Full Retreat$600 - Full Retreat with single room requestedPayment Type(Required)Select OneVenmoCash AppZelleI'll mail a checkLiability WaiverRelease of Liability Waiver(Required)RELEASE OF LIABILITY AGREEMENT I recognize there are risks, including those of injury and even death, in all the activities initiated and carried out under the auspices of Kentucky Retreats directed by Laurence Coppedge and Jeremiah Kuhn , and I and/or my legal guardians freely assume those risks on my behalf. I agree to release and hold harmless from liability, Shaker Village, Laurence Coppedge and Jeremiah Kuhn, other group leaders and agents in the event to my injury or death, resulting from negligence or any other theory of liability while engaging in any activity. I agree not to make a claim or file any lawsuits against Shaker Village, Laurence Coppedge and Jeremiah Kuhn or their representatives for injury or damages related to participation in: The Kentucky Retreats event on November 6-9, 2025 that might include hiking, canoeing, biking, or any other activity on the event. I HAVE CAREFULLY READ THIS RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS CONTENT. I AM AWARE THIS CONTRACT RELEASES LAURENCE COPPEDGE AND JEREMIAH KUHN FROM LIABILITY, AND I SIGN IT OF MY OWN FREE WILL. Effective dates of release: November 6-9, 2025 I agree to the terms and conditions.Signature(Required)Additional Comments Δ