Emmanuel III - Lien Doan Sinai

What: LDSN Huynh Trưởng, HSTT, and Trở Tá Christmas Season Retreat
Location: Saint Joseph Monastery (21010 Lucerne Valley Cutoff, Lucerne Valley, CA 92356)
When: Friday, 1/2/2026 at 5PM to Sunday, 1/4/2026 at 2PM
Cost: $40 for one person and $60 if you register with two people
- Last day to register: 12/19

Email Address of Individual Paying *(IMPORTANT: Email must match the email used in the payment page after submitting this form)

Participant

Saint Name *

First Name *

Last Name *

Email Address *

Đoàn Name *

Phone Number *

Birthday *

Gender *FemaleMale

Đoàn Trưởng's Full Name *

Đoàn Trưởng's Email Address *

Street Address *

City

State

ZIP Code

Doctor Name *

Doctor Phone Number *

Insurance Provider *

Insurance Group Number *

Insurance ID Number *

Known Allergies (including medications and food) *

Chronic medical, psychiatric concerns, or physical restrictions (ex: diabetes, behavioral related concerns, including alcohol/substance use, or physical disability) *

Name of Emergency Contact *

Emergency Contact Phone Number *

Relationship to Participant *

Waiver and Release *

I, (NAME ON THIS REGISTRATION FORM), an adult [age of majority, per State (e.g., 18 years old in California)] and I am the named participant, or I am the parent/guardian of the minor who will be participating in the above-mentioned event (“The Event”) organized and/or sponsored by the Vietnamese Eucharistic Youth Movement in the U.S.A. (“VEYM”). I am fully aware that my or my child’s participation in The Event is totally voluntary.

I am aware that The Event may involve the following activities but not limited to: running, jumping, sharing personal stories, singing, clapping, shouting, sitting for prolonged periods of time, early wake-up, sleeping in cabins, use of low-light restrooms, outdoor activities in dirt and rocky terrain, sleeping outdoors, activities relating to outdoor environment, aquatic activities, and OTHER TRAINING ACTIVITIES.

In consideration of VEYM’s agreement to permit me or my child to participate in The Event, the receipt and sufficiency in which consideration is hereby acknowledged, I agree as follows:

I, (NAME ON THIS REGISTRATION FORM), hereby: *

1. Release, acquit and forever discharge VEYM and their employees, volunteers, agents, servants, officers, trustees, representatives, affiliates, and sponsors, in their official and individual capacities, as well as my Parish and my Diocese, their employees and agents, representatives, sponsors, chaperones, or volunteers, from any and all liability whatsoever for any and all damages, injuries (including death) to persons, loss to property, or both, which arise during, out of, or in connection with my participation in The Event, which may be sustained or suffered by me, my child or any person in connection with any activities of The Event, including, but not limited to, those related activities directly or indirectly leading up to and stemming from The Event, even those activities which arise out of my travel to and from The Event; ________ (please initial for concurrence)

2. Agree to indemnify (compensate for harm or loss), defend and hold harmless the VEYM and their employees, volunteers, agents, servants, officers, trustees, representatives, affiliates, and sponsors, in their official and individual capacities, as well as my Parish and my Diocese, their employees and agents, representatives, sponsors, chaperones, or volunteers, against all claims, including, but not limited to, claims of negligence, unintentional acts, and acts of omission, and from any and all liability, loss or damage they sustain as a result of any claims, demands, actions, causes of action, judgments, costs or expenses they incur, including attorney’s fees, which result from or arise out of my or my child’s participation in The Event, including but not limited to, my travel to and from The Event. ________ (please initial for concurrence)

I hereby acknowledge and accept that: *

3. There are certain inherent dangers and foreseeable and unforeseeable risks of harm to myself, my child and other arising from The Event's various activities, including but not limited to, sustaining bodily or emotional injury, that could result from my participation in The Event. I have knowingly and voluntarily decided to assume the risks of these inherent dangers in consideration of VEYM's permission to allow me or my child to participate in The Event. ________ (please initial for concurrence)

4. Weather conditions, including Acts of God, or natural causes (which humans do not intervene to cause), may alter or affect plans, expenses, and activities relating to, and including, The Event, and I understand that inherent dangers and risks of harm to myself, my child and others as a result of such natural causes may vary, and I assume all foreseeable and unforeseeable risks of harm I or my child may be exposed to therefrom;________ (please initial for concurrence)

5. My or my child’s personal property may be at my risk of theft, damage or loss entirely; ________ (please initial for concurrence)

6. VEYM reserves the right to decline, to accept, or retain me or my child in The Event at any time should my actions or general behavior impede the operation of The Event or the rights or welfare of any other person. I understand that I or my child may be required to leave The Event in the sole discretion of VEYM’s agents and representatives. If I am or my child is required to leave, no refund will be given to me or my child for any unused portion of The Event, and VEYM will not reimburse me for any alleged direct or indirect costs or expenses I or my child incurred as a result of my or my child’s participation in The Event. ________ (please initial for concurrence)

7. I understand that VEYM, in its sole discretion, reserves the right to cancel The Event or any aspect thereof prior to commencement. In the event of cancellation of The Event in whole or in part, I accept that I or my child may not be reimbursed or refunded for any unused portion of The Event. ________ (please initial for concurrence)

I understand *

I represent and warrant that I am or my child is covered throughout The Event by a policy of comprehensive health and accident insurance which provides coverage for injuries which I or my child may sustain as part of my or my child’s participation in The Event. Even if I am or my child is not covered by any health insurance during The Event, however, I agree to complete the HEALTH INFORMATION section to the best of my ability and, by its completion, I hereby release and discharge VEYM of all responsibility and liability for any injuries, illnesses, medical bills, charges or similar expenses I may incur while participating in The Event. By completing the form, I hereby authorize VEYM to obtain any necessary medical treatment to myself or my child, consent to any necessary examination, treatment, or care under the supervision and/or advice of any properly licensed medical professional, and I explicitly authorize VEYM to release medical information about me or my child to any person or entity to whom VEYM refers me for medical treatment. ________ (please initial for concurrence)
I agree that this agreement is to be construed pursuant to the laws of the State of California and is intended to be as broad and inclusive as permitted by law, and if any portion hereof is held invalid, it is agreed that the balance hereof shall continue in full legal force and effect. In addition, I agree that any legal action arising out of or in relation to this agreement must be brought in _______ County, ______ State court.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence.
I hereby grant VEYM my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my name, voice, image, and/or likeness that arise from my participation in The Event, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at VEYM’s sole discretion.

IN SIGNING THIS AGREEMENT, I HEREBY ACKNOWLEDGE AND REPRESENT THAT I HAVE READ THIS ENTIRE DOCUMENT, THAT I UNDERSTAND ITS TERMS AND PROVISIONS, THAT I UNDERSTAND IT AFFECTS MY OR MY CHILD’S LEGAL RIGHTS, THAT IT IS A BINDING AGREEMENT, AND THAT I HAVE SIGNED IT KNOWINGLY AND VOLUNTARILY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

By initialing below, you understand the liabilities, risks, and assumptions of participating. Your initials representation will be applied to all initial request above.

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