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Date*

Date

Name of Retreatant*

First Name Last Name

Are you 18 years old or over?*

YesNo (If "No", please list name of parent or legal guardian below)

Name of Parent or Legal Guardian (if retreatant is under 18)

First Name Last Name

I give permission for the retreatant, who is under 18 years of age, to attend the above referenced retreat (If retreatant is under 18)

Yes, I give my permissionNo, I do not give my permission

Email of Retreatant (If over 18, otherwise parent or legal guardian email is required)*

example@example.com

What is the name of the group who will be responsible for the minor on retreat?

Name of group leader who will be responsible for the minor on retreat

Email of group leader responsible for minor on retreat

example@example.com

Phone Number of group leader responsible for minor on retreat

Area Code Phone Number

Phone Number (if over 18, otherwise parent or legal guardian phone number is required)*

Area Code Phone Number

Your Address (if over 18, otherwise parent or legal guardian address is required)*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parish*

Tee shirt size*

Known Allergies*

Yes (If "Yes", please list below)No

List Allergies Here

Emergency Contact*

First Name Last Name

Emergency Contact Number*

Area Code Phone Number

Will You Be Spending the Night on Friday?

YesNo

Retreat Center Rules & Regulations

Please arrive on time for start of retreat

Damage or cleaning fees may be assessed resulting from misuse of Saint Clare of Assisi Retreat Center.

You are welcome to move tables and chairs within the meeting room to suit your needs.

Please return items to their proper place prior to your departure.

Please do not remove furniture from the bedrooms or meeting rooms.

Please empty all trash and dispose in trash cans located on the back side of the Dining Hall area.

No amplified music or announcements outdoors without Saint Clare of Assisi Retreat Center’s permission.

Wireless Internet is available. Please check with retreat center coordinator for the password.

Smoking and alcoholic beverages are not permitted on the property.

Illegal drugs including marijuana are not permitted on the property.

Pets are not allowed.

Quiet time is from 11:00 PM to 7:00 AM

Please do not take food or dishes from the Dining Hall.

Please do not take or consume food or drink in Chapelor bedrooms.

Please make sure Library Door is locked at all times.

Only the Retreat Facility Coordinator has permission to operate the Audio/Visual System

Only the Retreat Facility Coordinator has permission to adjust air conditioning and/or heat settings.

Hold Harmless

I hereby agree to, indemnify, defend and hold harmless Facility Owner (and its officers, directors, partners, agents and employees) from and against any and all claims, actions, damages, liabilities and/or expenses (including, without limitation, attorney’s and other professional fees) that arise in connection with access to, and use of, the Reserved Room(s), Building and/or Property, including, without limitation, any and all claims, actions, damages, liabilities and/or expenses arising in connection with (i) a breach of Retreat Center Rules & Regulations, (ii) any misconduct and/or violation of applicable laws, ordinances, regulations, rules and/or requirements; and/or (iii) loss of life, bodily injury, personal injury and/or property damage that occurs during, or is otherwise related to, access to, and use of, the Reserved Room(s), Building and/or Property.

By signing, you agree to the follow the Retreat Center Rules & Regulations. You also agree to the terms of the Hold Harmless Agreement. If you are sponsoring a minor for this retreat, you give them permission to be on this retreat under the care of the group leader as listed above. *

Clear

Trust In Jesus

If Retreatant is 18 or older, skip next 4 questions