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PRO-ORB: Orthodox Youth Retreat

 Staff Chaperone/Adult Volunteer Application         

Name: _________________________________

Social Security Number: __________________


M or F? ____ Date of Birth: _________

Marital Status: ______________


Address: _______________________________




Home Phone: ____________________________

Work Phone: ____________________________

E-Mail: _________________________________


Do you have a valid driver’s license? YES NO


If yes, License state and #: ________________


Emergency Contact: _____________________

Address: _______________________________



Contact Phone: __________________________

Relationship: ____________________________



Name of Employer: __________________________



Address: ________________________________



Position ______________________________


Length of Employment: ___________________


Supervisor: ___________________________


Phone: _________________________________


Church Membership



Address: ____________________________


Diocese: _____________________________


How many years attending? ____________


Priest: ______________________________


Priest’s Phone: _______________________























Have You Ever Been Charged or Convicted of a Felony Offense?  Yes______           No_______

Circle All areas which best meet your Interests and Abilities:

Choir/Reader/Server     Nurse/Health               Kitchen: Cooking & Prep                    Water Safety/Lifeguard                Sports

Arts/Crafts/Games               Dorm Chaperone/Parent     Maintenance/Clean-up       Other: _________________________


Staff Fee:  $225.00/person (Covers all local lodging, meals, fees & local transportation costs)

Please enclose your payment & completed form and mail it to:

Winter Service Retreat 2009-2010

c/o St. George’s Orthodox Church

P.O. Box 667

Pharr, Texas USA 78577

PS  If your entire family is planning to come, please let us know as this will necessitate special arrangements for lodgings, meals, outings, etc. Family participants and families with younger siblings can either stay at the on-site motel-type lodgings at the Valley Baptist Retreat Center or may provide for their own lodging at a nearby motel. See Local Accomodations section for additional details.




¡Gloria a Dios por todo!
Direct your Questions, Comments or Feedback to (Por favor dirigir sus preguntas, dudas o comentarios al): 956-781-6114 or info@stgeorgepantry.org

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