Instructions to complete retreat application form:

Complete forms using Microsoft Word or hand write information. Email completed document, pages 1-3 to or by regular mail to address provided on page 4.

Retreat registrationdeadline: Dec. 15, 2012

Name______First Middle Last

Address______

City______State______Zip______

Phone______Email______

(Cell)

Church______Diocese______Pastor______

Date of birth______

Emergency contactperson: ______

Emergency phone #______

Any specialaccommodations or dietary needs?

Please list here______

Release of Liability – Please Read Carefully

In exchange for participation in the activity of “Go Down Moses Retreat”, organized by Holy Name Province and Sacred Heart Province, being held at St. Joseph Seminary, hereafter mentioned as “above named facilities and individuals”) facilitated by Ferd Cheri and Gerald Hopeck,December 27-30, 2012 and or use of the property, facilities and services of these entities, I agree to the following:

  1. I agree to observe and obey all posted rules and warnings and further agree to follow any oral instructions or directions given by the retreat leaders or the employees, representatives or agents of these organizations.
  2. I recognize there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and further release all of the above named individuals or organizations for injury, loss or damage arising out of my use or presence of the above named facilities whether caused by my fault or other third parties.
  3. I agree to indemnify and defend all above named individuals or entities against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other costs, which may in any way arise from my presence upon or use of the above named facilities.
  4. I agree to pay for all damages to the above named facilities caused by my negligence, recklessness or willful actions.
  5. Any legal or equitable claim that may arise from participation in the “Go Down Moses Retreat” shall be resolved under District of Columbia law.

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.

Dated: ______Signature: ______

Participant: ______

Address: ______

Permission to Use Photograph

Event: Go Down Moses Retreat

Location: Washington, DC

I grant to [Holy Name Province and Sacred Heart Province] the right to take photographs of me in connection with the above-identified event. I authorize [Holy Name Province and Sacred Heart Province], its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that [Holy Name Province and Sacred Heart Province] may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

I have read and understand the above:

Signature: ______

Printed name: ______

Address: ______

Date: ______

Mailing address to return registration form by US Post Office

Please allow mailing time of 3-5 business days to ensure arrival by registration deadline.

Br. Gerald Hopeck, OFM

Holy Name College

1650 St. Camillus Dr.

Silver Spring, MD 20903

For more information or for assistance in registering for the retreat please contact Br. Gerald by phone: 267.968.0464 or email:

Arrivals/Departures

Retreat participants are asked to arrive no later than 3:30 p.m. on Thursday, December 27. Departure is after 3:00 p.m. on Sunday, December 30, 2012.

Transportation

Airport: Please fly into Reagan National Airport

Train: Union Station

Bus: Mega or Bolt Lines are recommended

Take Metro to: Catholic University - arrangement will be made for someone to pick you up