YES! Retreat 2025

YES! Retreat Registration Form

High School Students, post-adolescent confirmation, ages 15-18
GENERAL INFORMATION
Parish *
Parent Full Name*

Parent First NameMiddle NameParent Last NameSuffix
Parent Phone Number*
Please enter a valid phone number.
Parent Email*
example@example.com
Teens Full Name*

Teens First NameTeens Last Name
Teens Email*
example@example.com

Palanca Information
Name

First NameLast Name

Medical Information
I grant to the retreat leaders and the Roman Catholic Bishop of Fall River, Corp Sole, its agents, employees,and representatives my permission to seek emergency medical attention for this child if, in their judgment, such attention is warranted and I am not immediately available to grant such permission. I agree to be in all ways responsible for any and all expenses associated with any and all medical care furnished to this child.*

YESNO
Participant's Primary Care Physician*
Physician Phone*
Policy #*
EMERGENCY CONTACT #1*

First NameLast Name
EMERGENCY CONTACT #1 Phone Number*
Please enter a valid phone number.
EMERGENCY CONTACT #2

First NameLast Name
EMERGENCY CONTACT #2 Phone Number
Please enter a valid phone number.
Does your child need to administer any prescription/ over the counter medication during this event?*

YESNO
If yes, please list the medication(s) and their dosages below. *
Does your child have any allergies to food and/or medications?*

NOYES
If yes, please list & explain.*

Photo Consent and Permissions
I grant to the Roman Catholic Bishop of Fall River, Corp Sole, its representatives and employees the right to take photographs of my child and his/her property in connection with the above-identified subject. I authorize the Roman Catholic Bishop of Fall River, Corp Sole, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the the Roman Catholic Bishop of Fall River, Corp Sole may use such photographs of child with or without his/her name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, and web content*

YESNO
The Roman Catholic Bishop of Fall River, Corp Sole has sufficiently explained the nature, extent, and requirements of this event and I am aware of and accept the associated risks of participation in this event. I agree to release and hold the Parish and the Roman Catholic Bishop of Fall River, Corp Sole and their agents, employees, and representatives, forever harmless and indemnified against and from any and all claims or right of action for damages which my child has or hereafter may acquire either before or after the child has reached majority, including but not limited to all bodily injuries and property damages, and including any legal fees in defending such a claim, resulting from, arising out of, or during, or in any way connected with this event. I also agree to release and hold the Parish and the Roman Catholic Bishop of Fall River, Corp Sole and their agents, employees, and representatives, forever harmless and indemnified against and from any and all claims or right of action for damages which my child has or hereafter may acquire either before or after the child has reached the majority, including but not limited to all bodily injuries and property damages, and including any legal fees in defending such claim, resulting from, arising out of, or during, or in any way connected with this event.*

I have read and understand information provided in this form.
I understand that this form does not finalize participation. A payment needs to be received prior to finalization.*

I understand
Signature*

Clear
Payment Type*

Pay ElectronicallyPay by Check

Pay by Check
RETREAT FEE: $220.00 (After January 31st 2025)

Make Checks Payable to: Diocese of Fall River

MEMO: YES RETREAT 2025

Mail to:

Diocese of Fall River

Attn: Oscar Rivera

423 Highland Ave

Fall River, MA 02720-3718

Payment must be received in order for Participant's registration to complete.

My Products

YES! Retreat (1) Participant FeeThis is the price for One Retreat Participant

$220.00

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

YES! Retreat Registration Form

GENERAL INFORMATION

Palanca Information

Medical Information

Photo Consent and Permissions