Every person attending the REZ retreat MUST fill out this form! This includes youth AND leaders.
Adult Leaders and Volunteers, please feel free to type "NA" for any questions which are not applicable to you. Be sure to press "SUMBIT" at the end of the registration before proceeding to the payment screen in Flipcause.com.

The REZ Retreat is facilitated by the Missioners of Christ, a Catholic Nonprofit Community & Apostolate.
www.missioners.org info@missioners.org 757-424-8774
Name of attendee *
I am a ......
Name of parish you attend *
Male or Female *
Attendee's Birth Date *
Attendee's age upon arrival to camp *
Grade* *
Address *
Attendee's Email *
Attendee's Home Phone (or "NA") *
Attendee's Cell Phone *
Have you attended other retreats or conferences? *
Yes, attended once
Yes, attended twice
Yes, attended more than 3 times!
DYC, Diocesan Youth Conference
Catholic Heart Work Camp
REZ Retreat
Foreign Mission
Domestic Mission
FOCUS Convention
Other Retreat
Application to participate
I am applying to participate on "The REZ" youth retreat, sponsored by the Missioners of Christ. I understand that I am expected to abide by all rules and guidelines of the retreat, as well as those of my youth ministry and the Triple R Ranch. I understand that a major part of a retreat is "fasting: from the conveniences in my daily life, and as such, I will not bring a cell phone or other web/data enabled device. Also, as the retreat builds on itself throughout the weekend, I understand that, except for an emergency, I cannot leave the retreat for another activity, as it will both take away from the retreat's impact for me as well as disrupt the flow for others.
Attendee's Signature *
Date *
Parents, please note that we try to "preserve" this time for your child, by doing our best to dramatically reduce outside distractions. As such, we request that your child not bring a cell phone or other web/data enabled device (digital cameras are permitted). If they have a cell phone with them, we will ask all attendees to turn them in when they arrive. You will be given multiple means of contacting us in a future emails before the retreat. Also, we ask that you allow your child to stay at the retreat for its full duration. While a 2 hour trip to an activity/game/practice may seem minimal, it disrupts the flow of the retreat for both your child as well as the other youth, especially those in his/her small group. Thank you for helping us keep this retreat a positively impacting experience for all.
Name of Parents/Guardian *
Phone Number of Parents/Guardian *
Email of Parents/Guardian *
Emergency Contact NAME Parent/Legal Guardian/Spouse (to be contacted in case of illness or injury) *
Emergency contact RELATIONSHIP to attendee* *
Emergency contact PHONE NUMBER* *
Attendee is allergic to:
Allergy Notes:
Dietary Restrictions: *
Dietary Notes:
Is the Attendee covered by medical insurance? *
Medication for youth attendees
"Medication" is any substance a person takes to maintain and/or improve health. This includes vitamins and natural remedies. The attendee's medication must be in the original container with their name and how the medication should be given. Please provide enough medication to last the entire weekend and hand medication in when you check in Friday evening. Medication will be administered by Dell Marie Bottone (Missioners of Christ, employee).
Will the attendee be taking daily medication? * *
Name of Medication
When is it given
Reason for taking it
Name of Medication
When is it given
Reason for taking it
The following non-prescription medications may be stocked at the REZ retreat and are used on an as-needed basis to manage illness and injury. Please check the ones the attendee can NOT be given. * *
Are all the Attendee's immunizations up to date? *
Year of Attendee's last Tetnus shot? *
If the attendee has not been fully immunized, please sign the following statement:
I understand and accept the risks to the attendee from not being fully immunized. If fully immunized, mark "NA"
Signature of Attendee or Attendee's parent/legal guardian: *
General Health History
Please select each statement that applies to the attendee. Please explain checked answers below.
Has/does the attendee: * *
Please explain all checked answers in the space below. For travel outside of the country, please name the countries visited and the month of travel.
Mental, Emotional and Social Health
Please select each statement that applies to the attendee. Please explain checked answers below.
Has the attendee: *
Please explain all checked answers in the space below, noting the number of the questions.
Consent to participate in camp:
Please check one: *
Additional Information
What have we forgotten to ask?
Please provide any additional information about the attendee's health that you think important or that may affect the attendee's ability to fully participate in the retreat. Attach additional information, if needed.
Authorization for Healthcare and Photo/Video Release
This heath form accurately reflects the health of the attendee. I authorize Missioners of Christ staff, medical providers (including physicians and EMT's) and/or my emergency contacts to authorize medical care and treatment, including invasive tests and/or surgery, for the attendee as any of them believe is reasonably necessary for the attendee's health and safety if I cannot be reached immediately. On behalf of the attendee, and his/her family, I release Missioners of Christ., and their employees, directors, contractors, volunteers and all medical providers, to the maximum extent legally permitted, from all claims arising from the attendee's medical care or treatment and I indemnify Missioners of Christ from any claims, costs, damages, expenses or losses. I authorize information on this form to be photocopied and/or shared with Missioners of Christ. I authorize the attendee's health-care providers to discuss and/or copy the attendee's health-care records for Missioners of Christ in an emergency. I understand that the attendee may be photographed or video taped during camp and that these images may be used in promotional material.
As a participant or parent/legal guardian of participant, I remain legally responsible for any personal action taken. I agree to hold harmless Missioners of Christ, Triple R Ranch and the Diocese of Richmond as well as its officers, directors, agents, chaperones, volunteers or representatives associated with this event, arising from or in connection with my child attending this event or including but not limited to accidents, emergencies, exposure to reckless conduct of persons.
This agreement shall be binding upon the parties hereto, their successors and assigns, upon due execution by you or a representative.

If a representative is signing on your behalf . . .
The undersigned represents that he/she is a representative authorized to sign on your behalf and to enter into this agreement.

Please enter your full name here to indicate that you are executing this agreement.

Signature of Attendee: (if over 18 years of age) *
Signature of Parent/Legal Guardian: *
Relationship to Attendee: *
Please enter today's date: * *
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