Young Adult Retreat Registration
The Young Adult Retreat is designed especially for young adults ages 18-30. It is a weekend to deepen your faith and take a break from the craziness of day to day life while spending time with a group of incredible young adults. Be sure to pay the $75 cost via our online store. Use a separate registration form for each young adult. Thank you!
contact@campkoinoniany.org
Last Name *
Your answer
First Name *
Your answer
Do you have a nickname you would prefer to be called during the retreat?
Your answer
Street Address *
Your answer
Street Address 2
Your answer
City *
Your answer
State *
Your answer
Zip+4 *
Your answer
Country *
Your answer
Phone (with area code) *
Your answer
Alternate Phone (with area code)
Your answer
Email *
Your answer
Additional Email
Your answer
Home Parish
Your answer
How did you hear about the Young Adult Retreat?
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number (with area code) *
Your answer
Are you up to date with your immunizations? *
PLEASE READ CAREFULLY AND RESPOND AT THE END. CAMP KOINONIA RELEASE AND WAIVER OF LIABILITY: This is a legally binding Consent Form and Release of Liability made voluntarily by me, the undersigned releasor, on my own behalf, and on the behalf of my heirs, executors, administrators, legal representatives and assigns to Camp Koinonia (aka Kamp Koinonia) -hereinafter “CK” or “Camp”. The undersigned hereby acknowledges that attending one of CK’s programs involves inherent risk of physical injury and assumes all such risks. The undersigned hereby agrees that for the sole consideration of CK allowing the undersigned to attend one of the Camp’s programs for which or in connection with which the Camp has made available any equipment, facilities, grounds or personnel for such programs or activities, the undersigned does hereby release and forever discharge CK, its members individually, and its officers, agents and employees of any and all claims, demands, rights and causes of action of whatever kind of nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequence thereof, resulting from participation in or in any way connected with the programs or activities at Camp. In an emergency, I acknowledge that I am solely responsible for all medical and other costs arising out of bodily injury or any loss sustained through participation in this activity. I authorize program staff to secure any licensed hospital, physician and/or medical personnel any treatment deemed necessary for the participant’s immediate care. By the execution of this agreement, I accept and assume full responsibility for any and all injuries, damages, and losses of any type, which may occur to me, and I hereby fully and forever release and discharge CK, its officers, employees, and insurers including any self‐insurance funds of the State from any and all claims, demands, damages, rights of action,present and future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of my participation in this class. I understand that the acceptance of this release and waiver of liability by CK shall not constitute a waiver in whole or in part of sovereign immunity by said Board, its members, officers, agents, and employees.I have read the above carefully before signing. Further, I understand that this release and waiver of liability shall include myself and members of my family, and shall be effective for all visits to Camp Koinonia, for one year from date of signature. I have read and fully understand the Release and Waiver of Liability Agreement and release of all claims. Young Adult Retreat Agreement: All participants of the Young Adult Retreat are guests of Camp Koinonia and are required to follow the following Camp policies and safety regulations: Camp Koinonia Young Adult Pool Policy: There is no lifeguard at Camp Koinonia. In order to maintain the safety of all of our campers, the following pool policy is in place. Swimming is allowed only when announced by the Program Director. No one is to be in the pool area at any other time. When the pool is open, there must be two adults on the pool deck at all times. While the pool is open, the designated Camp adult will have a phone and whistle with him/her at all times. If told to exit the pool, all swimmers must do so immediately. Family Camp Alcohol Storage and Consumption Policy: In the spirit of Family Camp, we expect drinking of alcohol to be done responsibly and in moderation. Hard liquor (such as whiskey, vodka, etc.), kegs or mass quantities of alcohol are not permitted on Camp property. Beer and wine, including wine coolers, are allowed to be stored by campers at the Camp Store only and consumed only in the evening when the store is “open” during regular store hours, as determined by the Spiritual Directors and Camp Manager. The store must close by midnight. Drinking of any alcoholic beverages is not permitted at other times or in other areas of the Camp. At the discretion of the Spiritual Directors in consultation with the Camp Manager, anyone found to be in violation of this policy may be asked to leave, without refunding of any fees paid. I have read and agree to follow the preceding guidelines. Treatment Authorization and Permission: I authorize CK staff to administer immediate and emergency medical treatment,including (1) transporting your child to a hospital emergency room or (2) calling the local rescue squad or ambulance. Photo & Video Release: I hereby give permission for images and/ videos of myself and my family members captured during Family Camp to be used by Camp Koinonia for the sole purpose of promotional material and publications, including but not limited to, the Family Camp website and related social media accounts. INDIVIDUAL CODE OF CONDUCT: Disciplinary action may be imposed whenever an attending individual commits or attempts to commit any act of misconduct at the Camp, or at any activity, function, or event sponsored or supervised by the Camp, including but not limited to: 1. Possession, use or distribution of an illegal or controlled substance, or look‐alike drug.2. Unauthorized and/or illegal possession, use or distribution of any alcoholic beverage. 3. Theft of property or services. 4. Intentional or willful and wanton destruction of property. 5. Assault and/or battery. 6. Possession of a weapon. 7. Conduct which constitutes harassment or abuse that threatens the mental well‐being, health or safety of any individual. Consequences include, but are not limited to: time out, notifying parents, and removal from the program for the safety and well‐being of other campers. *Disciplinary action may also be imposed whenever a student commits any acts of misconduct during an off‐site event or activity. I understand and agree to abide by the Code of Conduct. I acknowledge that I am fully aware of the consequences resulting from the violation of any of the guidelines and agree to comply with the Code of Conduct. *
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