PRO-ORB
Orthodox Youth Retreat Registration
& Emergency Contact Form
Parents: Please complete a separate form for each Youth or Young Adult attending.
Name of Participant: _______________________________________________
M or F (circle) Age: ___________ Birth Date____________________
Home Address: _______________________________________________
City/State/Zip: ________________________________________________
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 or Youth Retreats? (When & Where)_______________________________________________________
Family Email Address (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: $175.00 - Unless Motel-type room is desired, for which there will be an additional expense - please inquire!) The retreat fee covers local food, lodging, fees & local transportation expenses. Registration Forms & Fees are due before December 16th, unless other arrangements are made with the organizers. After December 15th, a LATE FEE of $10.00 must be added to the total cost, unless prior arrangements are made with the organizers. The Winter Retreat begins on Saturday evening, December 27, 2008 and officially concludes after Divine Liturgy and brunch on Friday, January 2, 2009. Guests are WELCOME to extend their stay through the weekend, until Sunday, January 4th after Divine Liturgy and Brunch. Let us know if you can stay through the weekend so we can make arrangements and discuss these with you! NOTE: Retreat Staff has the right to impose late fees or additional charges to those who do not make a payment at or before the due date. Special financial arrangements must be made in advance with the retreat organizers.
In addition to this “Registration & Emergency Contact Form”, I have completed, signed & am submitting the required:
* Permission Slip/Insurance Form/Guardian Release
* Medical History
*Border Crossing Permission Form
* 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: _______________
Driver’s License State and #: ________________________________
Cell Phone: _________________
Unless the person transporting your Youth Participant is your local Clergy or a member of our Retreat Staff, the Drivers License information will be verified before allowing participant to travel with named driver.
Participation Agreement:
The undersigned acknowledge that during participation at this PRO-ORB Orthodox Christian Youth 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 Youth 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 Youth 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’s Signature: ______________________________________________________
Date: _______________________
Youth Participant’s Signature: _____________________________________________
Date: _______________________
Valid Photo ID Required! Please Note & describe any special medical, physical or special dietary needs your Youth may have on the Permission Slip/Insurance Form.
