Information Form

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NAME

Gender

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Date of Birth

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Age

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Are you willing to be a driver in a car pool?

Do you need a ride to the retreat?

Emergency Contact Information

Phone Number to Contact in Case of Emergency

Emergency Contact's Name and Relation to Participant

Special Medical or Dietary Requirements

I assume responsibility for my own actions and safety on the retreat and therefore release the UMBC Catholic Retrievers and Archdiocese of Baltimore of any liability which may arise from my participation in this retreat.*

Registration For Fall Retreat $75.00

(If you need a scholarship/discount, contact Christy Oberst, Campus Minister, at [email protected].)

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