Medical Insurance Information
Emergency Contact (optional)
Note on Christian Environment
The spiritual formation offered at Shellbourne Conference Center (Shellbourne) is entrusted to Opus Dei, a Personal Prelature of the Catholic Church. The Prelature is committed to creating a Christian atmosphere in its activities where everyone feels welcomed, respected, and treated with the dignity of a child of God. The Prelature is committed to maintaining zero tolerance for abuse or behavior that detracts from the Christian atmosphere. It is imperative that everyone actively contributes to creating this Christian environment. If a Parent observes or is made aware of any behavior on the part of anyone else that is less than Christian, is suspicious, is inappropriate, or is a direct policy violation, then that Parent should share his/her observations with the Activity Director or the Prelature’s Safe Environment Coordinator, or call the Prelature’s reporting Helpline, 646-742-2741.
For comprehensive information on the Prelature’s Safe Environment Policy and Procedures please visit: https://opusdei.org/en-us/article/safe-environment-midwest-delegation/ Acknowledgement of Risk and Release of Liability
By entering my name below, I release the staff of Shellbourne Conference Center (Shellbourne) from any liability that may result from the Participant attending a Shellbourne activity (or in transportation to/from/during it). I agree that by signing this Acknowledgement of Risks and Release of Liability, I, on behalf of Participant, myself, and my heirs, agents, and assigns, hereby agree to waive, release, indemnify, hold harmless, and covenant not to sue Shellbourne, its Board of Directors, employees, agents, representatives, volunteers, insurers, assigns and successors, with respect to any and all claims, charges, and causes of actions, whether known or unknown, past, present or future, including, but not limited to, any and all costs, expenses, and attorneys’ fees, by reason of any injury, illness, death, damage, or loss, whether caused by negligence or for any other reason, arising out of, in connection with, or in any manner related to participation in Shellbourne activities. I represent that I, as parent/guardian with legal responsibility for the above-named Participant, am fully competent to enter into this Acknowledgement of Risks and Release of Liability; and that I, for myself, my heirs, my assigns, and next of kin, and any other parent or guardian of Participant, have carefully read this waiver and fully understand its contents and entered into this Acknowledgement and Release voluntarily and knowingly with an understanding of its ramifications. This Acknowledgment and Release is complete and signed of my own free will. I further certify that I have the legal authority to sign on behalf of myself, the student and family. Medical Release Form
By entering my name below, I authorize activity staff to seek medical assistance for Participant should the need arise. Photo Release Form
By entering my name below, I authorize any photography that includes Participant to be used for the purpose of promoting Shellbourne Conference Center (Shellbourne) programs. I understand that such photography remains the property of Shellbourne. Mentoring
By entering my name below, I authorize the staff of the activity to mentor Participant if the participant wishes. Mentoring is a one-on-one, in-person conversation with the goal to accompany the participant by setting goals related to the content of the activity.
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