2023 Sts. Joachim and Anna Diocesan Senior Retreat

Personal Information

• * First Name:
• * Last Name:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Email Address:
• * Confirm Email Address:
• * Date of Birth
• * Please list any dietary restrictions. Ex. Vegetarian
• * Please indicate your T-Shirt Size. (Ex. Adult Small, Adult Medium, etc.)

• Fee

  Type	Fee
  Registration and lodging at Camp	$130.00
  Registration and meals only	$80.00

Custom Information 1

• *

  Will you need overnight lodging at Camp?

  • Yes
  • No
• * What Jurisdiction are you from? (ex. Greek Orthodox Archdiocese, Ukrainian Archdiocese, etc.)
• * What is the name of your parish? What city and state is it in?

• Submitting your registration, you agree to: I/We understand that my/our insurance coverage for my/our family will be used as primary coverage in the event medical intervention is needed. I/we further understand that I/we will be responsible for any expense not covered by my/our insurance. I/We understand all reasonable safety precautions will be taken at all times by Camp Nazareth and its agents during Family Camp. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold the Carpatho-Russian Orthodox Diocese, Camp Nazareth, their leaders, employees, and/or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subjects of this form. I/We agree to indemnify and hold harmless, the Carpatho-Russian Orthodox Diocese, Camp Nazareth, their leaders, employees, and/or volunteer staff from any expenses, losses, claims, or damages incurred as a result of the acts or omissions of the subjects of this form.

Guest Information

You may add a maximum of 4