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MS Retreat Team Member Registration

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Piedmont Deanery Middle School Retreat 2023
YOU NEVER LET GO
Sunday, November 5 | 9AM to 4:30PM
Chestnut Ridge Camp and Retreat Center
4300 Camp Chestnut Ridge Rd, Efland, NC 27243
Thank you for your willingness to share your time and talent with our middle school youth. For more information, please contact the Youth Ministry Office at your parish or contact Melissa Parker.
RETREAT TEAM REGISTRATION
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- Registering For : REQUIRED Adult Retreat Team High School Youth/Young Adult Mentor Please fill out this field.
- For HS Youth Retreat/ Young Adult Mentors, Indicate Grade in School Year 2023-2024
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parish Affiliation REQUIRED Please fill out this field. Please enter valid data.
- Parish City/Town REQUIRED Please fill out this field. Please enter valid data.
- Safe Environment Certification Status REQUIRED Approved and Current Level C No Safe Environment Certification - For adults aged 26 and older, please contact your parish's Safe Environment Coordinator to initiate certification process before September 15, 2022 HS Youth/Young Adult Mentors - Please complete the Diocese of Raleigh Application for Volunteer Service at https://tinyurl.com/dor-formb. Email completed form to Melissa Parker at mparker@stmchapelhill.org Please fill out this field.
- Photo Authorization REQUIRED
  There may be times in which your photo may be taken individually or with a group during this event. These photos are sometimes displayed in the Church or used on our parish web site and bulletin. No names will be used in connection with these photos.
  Yes No Please fill out this field.
- Food/Medical Allergies, Special Needs, or Requests
- Emergency Contact Information (Parent Contact for Minors)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email Please enter an email address.
- Statement of Consent & Release of Liability
  
  I hereby waive any claims against, and RELEASE AND HOLD HARMLESS AND INDEMNIFY, the Piedmont Deanery, the Diocese of Raleigh, and any of their religious, employees, staff, volunteers, agents and representatives from any liability, claim, loss, damage, cost or expense arising from my participation in this event. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
  
  By submitting this form, I agree to the statements outlined above.
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Contact Us
- Melissa Parker
  
  Middle School Youth Ministry Coordinator
  
  919.942.6238
  mparkerstmchapelhill.org