Retreat

Name*

Phone Number*

Your email*

Address (parents/permanent)*

Date of Birth*

Sex*

Male

Female

Emergency Contact Name & Relationship & Phone Number*

Do you have any dietary restrictions or allergies?*

Are you currently taking any prescription medication or have you in the last 6 months? If so list them, with dosage and reason for taking.*

Do you have any emotional, physical, or sensory conditions? List any that may impede participation at the retreat.*

I agree on behalf of myself to hold harmless and defend the Catholic Campus Ministry of Radford University and the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with this event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese, its employees and agents and chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese. I hereby warrant that to the best of my knowledge that I am in good health. In the event of any emergency, I hereby give permission to be transported to a hospital for emergency medical or surgical treatment. In the event of an emergency, the noted emergency contact will attempt to be notified. I will not hold the Catholic Campus Ministry of Radford University and the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.*

Agree

I give permission for pictures and/or video of myself who will be engaged in activities related to the parish or Diocesan event to have their pictures posted in the Catholic Campus Ministry of Radford University and the Diocese of Richmond publications or websites.*

Agree

Disagree

Catholic Campus Ministry
at Radford University

Bishop Knestout encourages anyone aware of sexual abuse of minors on the part of clergy or staff of our diocese to notify civil authorities, call the Attorney General’s Clergy Abuse Hotline at
1-833-454-9064, and reach out to the Diocesan Victim Assistance Program at 1-877-887-9603..

Catholic Campus Ministry at Radford University

Bishop Knestout encourages anyone aware of sexual abuse of minors on the part of clergy or staff of our diocese to notify civil authorities, call the Attorney General’s Clergy Abuse Hotline at 1-833-454-9064, and reach out to the Diocesan Victim Assistance Program at 1-877-887-9603..

Catholic Campus Ministry
at Radford University

Bishop Knestout encourages anyone aware of sexual abuse of minors on the part of clergy or staff of our diocese to notify civil authorities, call the Attorney General’s Clergy Abuse Hotline at
1-833-454-9064, and reach out to the Diocesan Victim Assistance Program at 1-877-887-9603..