PROCLAIM - Epiphany Youth Retreat 2026

Participant's Name:*

First NameLast Name
Pronouns:
Congregation & City:*
Congregation & City*
If you selected "Other", please include the name of your congregation above.
Grade:*
Birthdate*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lodging: Please select the lodging that best accommodates your child’s needs. Overnight rooms/bathrooms will align with your selection .*

Boy's HousingGirl's HousingGender Neutral Housing

Parent/Gaudian Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Would you like to add contact info for a second parent/guardian?

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact

Someone other than parent/guardian.
Full Name:*

First NameLast Name
Phone:*
Please enter a valid phone number.

Liability Release:

For and in consideration of participation in the PROCLAIM - Epiphany Youth Retreat 2026, I acknowledge and agree to the following:

1. By virtue of my child’s participation they risk serious bodily injury.
2. I knowingly and freely assume all such risk.
3. I allow my child to be transported by chaperones to offsite locations as required in the trip schedule, and as arranged in advance.
4. I (we), the undersigned parent(s)/guardian(s) do release, hold harmless and promise not to sue The Episcopal Diocese of San Diego, their officers, agents, employees and chaperones, with respect to any and all such injury, except that injury or loss which results from the gross negligence or willful or wanton misconduct of one of those individuals or organizations.
5. I will inform my child that he/she must follow all safety rules and instructions or directions given during participation in the event, and that my child’s failure to follow instructions may result in my obligation to retrieve my child if requested. Additionally, I will not allow my child to attend if there are signs of illness.
6. My child and I (we) realize that participation in the program is voluntary.
7. My child will abide by the code of conduct.
Do you acknowledge and agree to the Liability Release stated above.:*

I agree.
Filming and Photo Release for Youth:
I hereby grant to The Episcopal Diocese of San Diego and to its employees, agents, assignees, chaperones the right to photograph and film my dependent and use the photo and or film or other digital reproduction of them or other reproduction of their physical likeness for publication processes, whether electronic, print, digital, or electronic publishing via the internet. Pictures of children will never be tagged by name.
Do you agree to the Filming and Photo Release for Youth stated above?*

I agree.I do not agree.
Parental Consent:
This is to certify that as a parent/guardian of this participant, I do consent to their waiver and release as set forth above. I also affirm that all information on the registration form is accurate.
Parent/Guardian Signature:

Clear
Today's Date:

MonthDayYear
Date
Participant's Code of Conduct

All participants of PROCLAIM - Epiphany Youth Retreat 2026 are expected to support our community by following the guidelines below.
- I will follow all schedules, rules, guidelines and emergency procedure plans of the program and facility.
- I will report any emergencies, concerns and safety issues immediately to adult leaders or chaperones.
- I will not bring technology to camp. This includes phones, tablets, laptops, and handheld gaming devices.
- I will socialize only in public areas prior to curfew.
- I will behave in a manner as not to hurt anyone verbally, emotionally, or physically.
- I will not use profanity and other unacceptable language.
- I will use kind words and language and not behave in a manner as to not put down, ridicule or make fun of another person.
- I will work towards making the event a good and safe time for everyone
  
  We have read and agree to comply with the code of conduct. We understand that breaking the code of conduct will result in consequences up to and including a parent coming to pick me up from camp.
Participant's Signature:*

Clear
Parent/Guardian's Signature:*

Clear

Payment: $225

PROCLAIM - Epiphany Youth Retreat 2026
PLEASE NOTE: Payment is due at the time of registration. The full cost for each participant in this program is $225 per person. The Episcopal Diocese of San Diego has planned to cover $50 per student. We will realize that $175 per student may still be out of reach for some participants. Families are asked to prayerfully discern what they are able to contribute and indicate that amount in the payment field. If you would like to contribute above the $175 to assist other youth participants, you may do that also.

Please review the instructions above and then enter the amount you are paying.

USDPROCLAIM - Epiphany Youth Retreat 2026

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Parent/Gaudian Information

Emergency Contact

Participant's Medical Information

Payment: $225