High School Retreat

Participant Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Country * none selectedAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte D'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic People's Republic of KoreaDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar(Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorthern IrelandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaRéunionSào Tomé And PríncipeSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaScotlandSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWalesYemenZambiaZimbabwe

Email *

Cell Phone

Home Phone

Birthday *

Special Needs?

Special diet? NoneBlandDiabeticGluten FreeLactose intoleranceLow cholesterol low fat and low sodiumFood allergies: describe below

Disability accommodations? NoYes

Comments

Parent's name *

Parent's phone *

Parent's email *

Medical Insurance Information

Insurance Name *

Policy Holder *

Policy Number *

Emergency Contact (optional)

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

Release Statements

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/

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.

By entering my name below, I authorize activity staff to seek medical assistance for Participant should the need arise.

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.

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.

Full name of parent or guardian as signature *

Payment Information

Payment method: Credit or Debit CardPay Later

 

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