PRO-ORB: Orthodox Youth Retreat
Staff Chaperone/Adult Volunteer Application
Name: _________________________________ | M or F? ____ Date of Birth: _________ Marital Status: ______________
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Address: _______________________________________________________________________________________________________________
| Home Phone: ____________________________ Work Phone: ____________________________ E-Mail: _________________________________
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Do you have a valid driver’s license? YES NO
| If yes, License state and #: ________________
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Emergency Contact: _____________________Address: _______________________________ ________________________________________
| Contact Phone: __________________________ Relationship: ____________________________
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Employment
Name of Employer: __________________________ _______________________________________
| Address: ________________________________________________________________________
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Position ______________________________
| Length of Employment: ___________________
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Supervisor: ___________________________
| Phone: _________________________________
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Church Membership
Parish:______________________________
| Address: ____________________________
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Diocese: _____________________________
| How many years attending? ____________
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Priest: ______________________________
| Priest’s Phone: _______________________
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References
Name
| Address
| Phone
| Relationship
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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
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.
