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: ____________________________

Employment

Name of Employer: __________________________ _______________________________________	Address: ________________________________ ________________________________________
Position ______________________________	Length of Employment: ___________________
Supervisor: ___________________________	Phone: _________________________________

Church Membership

Parish:______________________________	Address: ____________________________
Diocese: _____________________________	How many years attending? ____________
Priest: ______________________________	Priest’s Phone: _______________________

References

Name	Address	Phone	Relationship

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:  $175.00/person (Covers local lodging, meals, fees & transportation costs)

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

Winter Youth Retreat 2007-2008

c/o St. George’s Orthodox Church