ECHO: Houma Registration Form

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PARTICIPANT'S NAME* This field is required.
First Name
Last Name
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SEX* This field is required.
Male
Female
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DATE OF BIRTH* This field is required.
Month
Day
Year
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AGE AT THE TIME OF RETREAT* This field is required.You must be at least 18 years of age AND one year out of high school to qualify for this retreat.
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CONTACT INFORMATION
Email Address
Mobile Phone Number
Home Phone Number
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MAILING ADDRESS* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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DIOCESE & PARISH INFOThis retreat is initially only open to those from the Diocese of Houma-Thibodaux. However, available spots will open to the general public one month prior to the retreat.
Name of Diocese
Name of Church Parish
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INSURANCE & PHYSICIAN INFO* This field is required.In the event of an emergency, we want to be able to get you the medical services you need. Please carefully fill out the information below.
Name of Health Insurance Provider
Policy Number
Name of Primary Care Physician
Phone Number of Primary Care Physician
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EMERGENCY CONTACT PERSON* This field is required.In case of an emergency, who would you like us to contact?
Name of Emergency Contact Person
Phone Number of Emergency Contact Person
Relationship to Participant
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MEDICAL & ENVIRONMENTAL ALLERGIESPlease list below any medicines you are allergic to, as well as any environmental allergies we should be aware of.
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DIETARY RESTRICTIONSWe do our best to provide great food options for those with dietary restrictions. However, our cooks are not always able to accommodate every situation. If this situation arises, we will contact you regarding your dining options.
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MEDICAL LIABILITY WAIVER* This field is required.I hereby authorize Dumb Ox Ministries and/or the Diocese of Houma-Thibodaux to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness for myself. This authorization inclusively extends from June 25-29, 2021. I hereby warrant, to the best of my knowledge, I am in good health, and I assume all responsibility for myself. In the event of an emergency, I hereby give permission to transport me to a hospital for emergency medical or surgical treatment. I ask you to advise the person(s) listed as the emergency contact to any further treatment by the hospital or doctor. I assume full financial responsibility for any medical treatment expenses I may incur. I agree to either pay for services upfront, or if Dumb Ox Ministries or the Diocese of Houma-Thibodaux pays, I agree to be billed and reimburse their expense.
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PAST ECHO EXPERIENCE
Yes
No
Is this your first ECHO?
If you answered "no" above, please list any past ECHO experiences you've attended.
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BRIEFLY EXPLAIN WHY YOU WANT TO ATTEND* This field is required.ECHO is an immersive experience into the depths of our identity as men and women through the lens of St. John Paul II's Theology of the Body. We explore themes of sexuality, vocation, prayer, and relationships. We want to make sure you want to dive in!
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HOUSING OPTIONLumen Christi Retreat Center offers both single occupancy and double occupancy rooms with private bathrooms. However, due to COVID-19, Lumen Christi is only housing one person per room. In the event restrictions are lifted, some participants may need to share a double-occupancy room. In the event this occurs, if you are comfortable sharing a room with another participant, please list their name below.
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GENERAL LIABILITY WAIVER* This field is required.I understand that I remain legally responsible for any personal actions. I agree on behalf of myself, heirs, successors, and assigns, to hold harmless and defend Dumb Ox Ministries, the Diocese of Houma-Thibodaux, Lumen Christi Retreat Center, their officers, directors, agents and staff, chaperons, or representatives associated with the event, arising from or in connection with my attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate Dumb Ox Ministries, the Diocese of Houma-Thibodaux, Lumen Christi Retreat Center, their officers, directors, staff, agents, chaperones, or representatives associated with the activity for reasonable attorney fees and expenses arising in connection therewith.
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A NOTE ABOUT OUR COVID-19 PRECAUTIONS

In order to do our best to protect against the spread of COVID-19, below is our current policy in order to prevent the spread of COVID-19. These precautions are subject to change based off of state and CDC recommendations at the time of the retreat.

Temperature Checks: We will have a mandatory temperature check upon arrival to Lumen Christi Retreat Center prior to checking in. If a fever is detected, we will not be able to allow you to attend. Additionally, we will have a daily temperature check each morning of the retreat.

Face Mask Policy: Face masks will be required indoors at all times, except for when eating, drinking, showering, or sleeping. Face masks are optional outdoors as long as social distance is maintained. Retreat speakers and musicians, while performing their duties at sessions, Mass, etc, will not be required to wear face masks.

Social Distancing: We ask that social distance be maintained as much as possible throughout the duration of the retreat.

Regular Cleaning and Disinfecting: All common areas will be regularly cleaned and disinfected before and after use. Hand sanitizer will be available in common areas.

PLEASE NOTE: While we will do our best to minimize the risk of the spread of COVID-19, there is no such thing as no risk. It is up to you to discern your decision to attend. ECHO is a retreat rooted in authentic relationships with God and with the community. We are on the journey alongside you as we discover how we can bring together the reality of “social distance” with real connection. We strive to do everything we can to preserve these opportunities for authentic community, while at the same time keeping everyone safe. However, there is never no risk involved. As we say often, love looks forward! We will rely on everyone’s help to love one another well by abiding by the precautions, while at the same time encouraging everyone to take advantage of all the opportunities to grow in friendship and community.
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COVID-19 WAIVER* This field is required.In the unprecedented times of COVID-19, Dumb Ox Ministries and the Diocese of Houma-Thibodaux recognize the additional potential risks posed by the virus and its high infection rate. As our summer activities are likely to occur during Louisiana’s multi-phase reopening, our program participants are required to read the protocols that follow and follow all protocols throughout their time to promote their safety and the safety of the other program participants, hosts, Dumb Ox staff, the Diocese of Houma-Thibodaux staff, and those with whom they will interact at Dumb Ox events. (1) I agree to follow all safety protocols as recommended by the CDC in regards to COVID-19. I also agree to follow those recommendations specific to Louisiana as laid out by the office of the governor, as the reopening of the state progresses. Dumb Ox Ministries or the Diocese of Houma-Thibodaux may also add additional safety protocols to these lists as it sees fit. (2) I agree to follow all safety protocols for the duration of the event, at all times and in all places, including but not limited to, the properties of Lumen Christi Retreat Center. (3) I agree to hold Dumb Ox Ministries, the Diocese of Houma-Thibodaux, their staff, board of directors, volunteers (including any hosts or host families), program participants, and their insurers harmless from and against any and all liability, claims, demands, lawsuits, and expenses arising from personal injury, sickness, death, or property damage, including any costs related to medical treatment or injuries resulting from a COVID-19 infection. (4) I am aware that COVID-19 is highly contagious and I agree to assist Dumb Ox and the Diocese of Houma-Thibodaux in taking these precautions for my safety and that of others.
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PHOTO RELEASE & VIDEO CONSENT* This field is required.In consideration of the taking and use of the photographs or video footage of the named below, for good and valuable consideration herein acknowledged as received, I hereby grant to Dumb Ox Ministries and the Diocese of Houma-Thibodaux the irrevocable and unrestricted right and permission to take, use, re-use, publish photographic pictures of me or those of which I may be included, made through any medium and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any published matter in conjunction therewith. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or another matter that may be used in connection therewith or the use to which it may be applied. In exchange for the benefits derived by my participation, I hereby agree that I, my heirs, distributes, guardians, legal representatives, and assigns to do release and will indemnify, hold harmless the photographer or videographer, Dumb Ox Ministries or the Diocese of Houma-Thibodaux, for claims for libel or violation of any right of publicity or privacy or privacy arising out of or in connection with my participation in the photography or videography project, from whatever cause, including the active or passive negligence of the photographer, videographer, Dumb Ox Ministries, or the Diocese of Houma-Thibodaux.
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ECHO CODE OF CONDUCT* This field is required.VIOLATIONS OF ANY OF THE REGULATIONS LISTED BELOW MAY RESULT IN YOUR IMMEDIATE RETURN HOME AT YOUR EXPENSE: 1. All retreat directors, chaperones or counselors are to be respected at all times; instructions are to be followed. 2. Alcoholic beverages, tobacco, illegal drugs, and weapons or dangerous items of any sort are positively forbidden. 3. Room assignments may not be changed once assigned. 4. Unmarried members of the opposite sex may not visit each other’s rooms at any time. 5. Inappropriate public or private displays of affection are not allowed at any time during the camp. 6. Anyone damaging property will be held responsible for the cost of damages. Dumb Ox Ministries, the Diocese of Houma-Thibodaux, and Lumen Christi Retreat Center are not responsible for damage expenses that an individual incurs. Theft of property is forbidden. 7. You must be on-time for all scheduled activities. Failure to follow this rule may result in loss of privileges at this camp. 8. Obscene or abusive language, and inappropriate comments will not be tolerated. 9. Modesty in dress and behavior is required. 10. Participants must act as positive role models at all times during the camp and respect the property and residents of Lumen Christi Retreat Center. 11. Participants must participate in all scheduled activities. 12. CAMPERS ARE RESPONSIBLE FOR VALUABLES. Please do not bring valuables such as jewelry, expensive electronics, etc. Dumb Ox Ministries, the Diocese of Houma Thibodaux, and Lumen Christi Retreat Center are not responsible for loss, damage, or theft that may result to such items.
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CANCELLATION POLICY* This field is required.1. There is a non-refundable deposit of $75 required to secure your spot at ECHO. In the event of cancellation for any reason except for confirmed COVID-19 exposure, this amount cannot be refunded. 2. If cancellation occurs on or before Friday, June 11, 2021 (10 business days prior to the retreat), you will be refunded any monies paid over $75. 3. If cancellation occurs after Friday, June 11, 2021, except for cancellation due to confirmed COVID-19 exposure, we are unable to reimburse any ECHO registration fees and you are still responsible for the full registration balance.
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ECHO REGISTRATION FEES:

ECHO RETREAT COST:
$275.00

*We require at least a $75 deposit to secure your spot at ECHO.

*Registration cost covers all food, lodging, and retreat supplies. You are only responsible for your transportation to and from retreat.

*We do offer customizable payment plans, fundraising tools, and limited scholarships to those in need. Email us at echocamp@dumboxministries.com to inquire.
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PAYMENT METHODSWe are able to accept online payments via credit and debit cards as well as mail-in checks. A $75 deposit is required to secure your spot at ECHO.
I will pay my $75 deposit via mail-in check, and remaining balance by June 11th.
I will pay my $75 deposit online via debit or credit card, and remaining balance by June 11th.
I will pay in full via mail-in check.
I will pay in full now via debit or credit card.
My church is covering my registration cost.
Please select your preferred payment method
If your church is paying, please add name of the church contact person
If your church is paying, please include the church contact person's phone number
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SIGNATURE OF AGREEMENT* This field is required.By signing below, you agree to all the terms and conditions listed in the above Medical Liability Waiver, General Liability Waiver, COVID-19 Waiver, ECHO Code of Conduct, and the Cancellation Policy.
Clear
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CONGRATS, YOU DID IT!

Upon clicking submit, you will be automatically directed to our payment info page, where you can pay online and/or get mailing info to send a check.

Upon receiving your registration form and initial payment, we will send you confirmation of your acceptance via email along with a packing list and arrival info.

Contact us at (985) 951-2215 or at echocamp@dumboministries.com with any questions or concerns. We can't wait to see you at ECHO: Houma!
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