Orthodox Youth Retreat Registration
& Emergency Contact Form
Please complete a separate form for each Youth or Young Adult attending.
Name of Participant: _______________________________________________
M or F (circle) Age: ___________ Birth Date____________________
Home Address: _______________________________________________
Name/s of Parents or Legal Guardians:
Parent/s or Guardian Home Address (if different from above):
Home Phone: __________________ Cell Phone/s: ___________________
Parent/s or Guardian Work Phone/s (please specify who & where):
Other Emergency Contact Information (Name, Relationship, Phone):
Home Parish, Jurisdiction & Priests Name & Phone #:_______________
Previous Orthodox Summer Camps, OCF or other Retreats? (When &
Email Address/es (for future events), Optional:_________________
Enclosed is a Payment in the Amount of $________
I understand that the cost of the Winter Retreat is $200.00 per youth/young adult attendee. (Adult Chaperone/Parent/Visiting Clergy Staff Fee: $200.00 as well - Unless Motel-type room is desired, for which there will be an additional expense - Please inquire!) The retreat fee covers all local food, lodging, fees & local transportation expenses. This year, our Winter Retreat begins on Sunday Evening, December 29th, 2013 and officially concludes after Divine Liturgy and brunch on Friday Morning, January 3, 2014.
In addition to this “Registration & Emergency Contact Form”, I have completed, signed & am submitting the required:
* Permission Slip/Insurance Form/Guardian Release
* Medical History
* Medical Dispensation (if medications are necessary)
* Transportation Plans & Participation Agreement Form
Transportation Plans for Youth Participants:
_____ Parent or Guardian will be bringing and/or picking up retreat participant.
_____ Parent or Guardian has made arrangements for participant’s transportation.
_____ Participant will be taking the bus to McAllen or flying into the McAllen or Harlingen, Texas airport and Parent or Guardian has made appropriate arrangements for both arriving and returning transportation. (If pre-arranged, organizers will be glad to pickup participants from the airport or McAllen bus station if at all possible.)
Name of person picking up youth participant: ___________________________
Home Phone: _______________
Cell Phone: _________________
The undersigned acknowledge that during participation at this PRO-ORB Orthodox Christian Winter Service Retreat, while at St. George’s Orthodox Church, at places of lodging, and at any other facilities, on outings or while at service locations used for supervised retreat-related activities, certain risks and dangers may occur. These include, but are not limited to, loss or damage to personal property, physical or psychological damages and/or injury, not excluding fatality, due to accidents, which may occur. I also acknowledge that participants may be transported off the retreat facility site for supervised retreat-related outings and activities.
In consideration, and as a part of the right to participate in this PRO-ORB Orthodox Christian Winter Service Retreat Program, I have and do hereby assume all of the above risks and any other ordinary risk incidental to the nature of these activities which are not specifically foreseeable, and will hold the Puente del Rio Ortodoxo – Orthodox Rio Bridges (PRO-ORB), the Orthodox Church in America, the Orthodox Christian Winter Retreat Program, the staff or facility of St. George the Great Martyr Orthodox Church in Pharr, Texas or its clergy, and all others providing staffing or service to the Retreat, harmless from any and all liability actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss, which may arise in connection with the participant’s participation in this PRO-ORB sponsored Orthodox Youth Retreat Program affiliated with St. George’s Parish.
Parent or Guardian’s Signature: ______________________________________________________
Youth Participant’s Signature: _____________________________________________