Which of the following best describes your role?
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Youth 12-14 years old
Youth 15-18 years old
Head Advisor
Advisor/Chaperone
Clergy
Religious
Seminarian
Board Member
Other
Participant Name
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First Name
Last Name
Sex
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Male
Female
Date of Birth
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MM
DD
YYYY
Participant Email
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Participant Phone Number
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(###)
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Home Parish
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St. Elias - Birmingham, AL
St. Joseph - Phoenix, AZ
St. Ephrem - El Cajon, CA
Our Lady of Mt. Lebanon Cathedral - Los Angeles, CA
Our Lady of Lebanon - Millbrae, CA
St. John Maron - Orange, CA
St. Joseph - Riverside, CA
Our Lady of the Rosary - Sacramento, CA
Sts. Peter and Paul - Simi Valley, CA
St. Sharbel - Stockton, CA
St. Jude - West Covina, CA
St. Rafka - Lakewood, CO
Our Lady of Lebanon - Lombard, IL
St. Sharbel - Peoria, IL
St. Sharbel - Baton Rouge, LA
St. Sharbel - Clinton Twp, MI
St. Maron - Detroit, MI
Our Lady of Lebanon - Flint, MI
St. Rafka - Livonia, MI
Holy Family - Mendota Heights, MN
St. Maron - Minneapolis, MN
St. Raymond - St. Louis, MO
St. Anthony of Padua - Cincinnati, OH
St. Maron - Cleveland, OH
Our Lady of Lebanon Mission - Columbus, OH
St. Ignatius of Antioch - Dayton, OH
Our Lady of the Cedars - Fairlawn, OH
Basilica and National Shrine of Our Lady of Lebanon - North Jackson, OH
St. Maron - Youngstown, OH
Our Lady of Lebanon Mission - Norman, OK
St. Therese - Tulsa, OK
St. Sharbel - Portland, OR
Our Lady's Austin, TX
St. Sharbel Mission - El Paso, TX
Our Lady. of the Cedars - Houston, TX
Our Lady of Lebanon - Lewisville, TX
St. George - San Antonio, TX
St. Jude - Murray, UT
St. Sharbel Mission - Sturtevant, WI
Our Lady of Lebanon - Wheeling, WV
Other
T-Shirt Size
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Adult Sizes
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Roommate Request / Single Room Request (adults only, $100 extra)
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Are you a senior in high school this year?
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Adults: choose not applicable
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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(###)
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Medications (put 'N/A' if none)
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Allergies/Dietary Restrictions (put 'N/A' if none)
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Doctor's Name
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Doctor's Phone Number
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(###)
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Health Insurance Company Name
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Name of the Insured
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Health Insurance Policy / ID Number
Health Insurance Group Number
Waiver of Liability
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As a participant or parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named participant and/or minor (“participant”). I agree on behalf of myself and my child named herein to indemnify, hold harmless, and defend the Office of Youth Ministry for the Eparchy of Our Lady of Lebanon of Los Angeles (Maronite Youth Organization), its directors, volunteers, and representatives and the Eparchy of Our Lady of Lebanon of Los Angeles, its employees and agents, chaperones, and/or representatives associated with the event, from any claim arising from or in connection with my child’s actions and omissions, including any claim arising out of my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment that is claimed to be caused by my child in connection therewith, and I agree to defend, indemnify, and compensate the Office of Youth Ministry for the Eparchy of Our Lady of Lebanon of Los Angeles (Maronite Youth Organization), its officers, directors and agents, and the Eparchy of Our Lady of Lebanon of Los Angeles, its employees and agents and chaperones, or representatives associated with the event for cost of defense, reasonable attorney’s fees, and expenses, including litigation, medical, and all claim-related 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 Office of Youth Ministry for the Eparchy of Our Lady of Lebanon of Los Angeles (Maronite Youth Organization) or the Eparchy of Our Lady of Lebanon of Los Angeles.
Covenant of Behavior
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As the participant or parent/legal guardian of said participant in the Eparchy of Our Lady of Lebanon 2025-2026 MYO Regional Retreat, I understand that the directors and staff will strictly enforce the rules governing the retreat. I agree to abide by all the guidelines as established by the Office of Youth Ministry of the Eparchy and Our Lady of Lebanon, Los Angeles, CA, and to conduct myself in a CHRISTIAN manner. I am fully aware that I will be expelled from the program if I do not adhere to these guidelines. I, the participant or parent/legal guardian of said participant, accept financial responsibility for any damage to the rooms or property caused to any facility attended. I understand that removal from the event will occur at my own expense should conduct be deemed inappropriate.
PHOTO/VIDEO RELEASE
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I, the participant or parent/legal guardian of said participant, hereby give permission to appear in pictures and videos taken during this conference. I understand fully that these media items may be used by the Maronite Youth Organization and affiliates. This media will not be shared with any third-party unless deemed necessary or appropriate by the facilitators of the event.
TRAVEL/TRANSPORTATION RELEASE
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I, the participant or parent/legal guardian of said participant, hereby accept the travel requirements necessary to participate in this event and to travel to and from the retreat by commercial air/ground or other means. I also give my permission to the directors and advisors to make appropriate decisions regarding travel to and from the retreat and while attending any facility and function. These activities may require transportation to a location away from the event site. They will take place under the guidance and direction of representatives and/or volunteers from the Office of Youth Ministry for the Eparchy of Our Lady of Lebanon of Los Angeles (Maronite Youth Organization).*
MEDICAL TREATMENT RELEASE
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I, the participant or parent/legal guardian of said participant, fully understand that if illness or serious illness develops or injury occurs, medical or hospital care will be given. However, the staff is not responsible in the case of accidental injury or illness. I further understand that in case of serious illness or injury, the emergency contact provided will be notified. If it is impossible to reach said emergency contact, I request and give permission for EMERGENCY TREATMENT or SURGERY, as recommended by the staff and attending physician
