Men's Discernment Weekend Retreat Registration

Date of Submission*

Sponsoring Priest*

Parish of Sponsoring Priest*

Parish name if not listed above

Retreatant Basic Information

Name*

First Last

Age on date of retreat*

Your Home Parish*

Address*

Street Address City State ZIP Code

Mobile Phone*

Other Phone*

Email*

Will you have your own transportation during the Parish Visit?

Yes
No

Highest level of education completed*

Photo/Video Release

Photo/Video Release Consent*

I give consent to the Photo/Video Release. I grant the Diocese of San Jose, its directors, officers, employees, agents, and designees (collectively “DSJ”) non-revocable permission to capture my image and likeness in photographs, videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that DSJ will own such Images and further grant the DSJ permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to DSJ business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the DSJ prior to its use. I forever release and hold the DSJ harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity. No compensation to be given.

COVID 19 Safety

Safety during COVID-19: To keep everyone safe, we ask that all retreat participants show proof of having received the COVID-19 vaccine or show proof of a negative test result taken 1-2 days before the retreat. *There is a cost-free county COVID-19 test, which usually gives results the next day (https://scl.fulgentgenetics.com/appointment/screen/landing).
If you have symptoms of COVID-19, please do NOT come to the retreat; stay home and get well soon! We will comply with the recommendations of the Diocese of San Jose (https://www.dsj.org/update-on-covid-protocols/): “Masks will be required for all at indoor worship except presiders, deacons, and lectors when they are proclaiming the Word, leading prayer, or preaching at least six feet from anyone else and except cantors while they are singing at least 12 feet from anyone not of their household.”

Consent

I read the Diocese of San José's COVID 19 Safety protocol and will show proof of vaccination or COVID test result prior to retreat.

Activity Waiver

Activity General Liability Waiver*

I have read and consent to the waiver as written below for Men's Discernment Retreat event.

TO THE EXTENT PERMITTED BY LAW, I HOLD THE PARISH/SCHOOL AND DIOCESE OF SAN JOSE HARMLESS FROM ANY CLAIM OF INJURY, SICKNESS, ILLNESS OR DAMAGE THAT I /MY CHILD MAY SUFFER OR SUSTAIN DURING THE ACTIVITY LISTED ABOVE, WITH EXCEPTION TO INJURY OF DAMAGES ARISING OUT OF THE SOLE NEGLIGENCE OF THE PARISH/SCHOOL OR DIOCESE OF SAN JOSE. I ATTEST THAT I AM/MY CHILD IS PHYSICALLY FIT TO PARTICIPATE IN THIS EVENT.

IN THE EVENT THAT I/MY CHILD BECOME(S) ILL OR INJURED, I DO HEREBY CONSENT TO WHATEVER MEDICAL TREATMENT(S), INCLUDING BUT NOT LIMITED TO X-RAY, EXAMINATION, OR HOSPITAL CARE, CONSIDERED NECESSARY IN THE BEST JUDGEMENT OF THE ATTENDING PHYSICIAN AND PERFORMED BY OR UNDER THE SUPERVISION OF A MEMBER OF THE MEDICAL STAFF OF THE HOSPITAL AND/OR OTHER MEDICAL FACILITY PROVIDING THE TREATMENT. I AM NOT AWARE OF ANY MEDICAL CONDITION WHICH WOULD RENDER IT INAPPROPRIATE FOR ME TO PARTICIPATE IN ANY ACTIVITY ASSOCIATED WITH THIS EVENT.

Further, the novel coronavirus, COVID-19, is a highly infectious, life-threatening disease declared by the World Health Organization to be a global pandemic. There is no current vaccine for COVID-19. COVID-19’s highly contagious nature means that contact with others, or with surfaces that have been exposed to the virus, can lead to infection. Additionally, individuals who may have been infected with COVID-19 may be asymptomatic for a period of time or may never become symptomatic at all. Because of its highly contagious and sometimes “hidden” nature, it is currently very difficult to control the spread of COVID- 19 or to determine whether, where, or how a specific individual may have been exposed to the disease.

Therefore, I acknowledge the contagious nature of COVID-19 and the fact that it can be difficult to identify in another person, and the inherent risks of exposure at this event to those who may be infected with COVID-19. I voluntarily assume the risk that I/my child may be exposed to or infected by COVID-19, or other infectious virus or disease, by participating in this event and that such exposure or infection may result in personal injury, illness, permanent disability, and/or even death.

I further acknowledge that the CDC and many other public health authorities continue to recommend social distancing and other protective measures to prevent the spread of COVID-19. I/my child acknowledge that I/my child must comply with all set procedures to reduce the spread of COVID-19 while Participating.

I understand that the PARISH/SCHOOL AND DIOCESE OF SAN JOSE have put in place new rules and precautions in order to mitigate the spread of COVID-19, which rules and precautions may be updated at any time. While acknowledging that these rules and precautions may or may not be effective in mitigating the spread of COVID-19, I/my child agree to comply with such rules and precautions which may include, but are not limited to, wearing a face covering, hand washing, hand sanitizing, and social distancing.

I understand and acknowledge that given the unknown nature of COVID-19, it is not possible to fully list each and every individual risk of contracting COVID-19. I/my child understand that the risk of becoming exposed to or infected by COVID-19 during my Participant service may result from the actions, omissions, or negligence of myself and others, including, but not limited to, priests, parish/school/diocesan staff, Participants, and other parish/school/diocesan workers, including their families. I/my child recognize that the PARISH/SCHOOL AND DIOCESE OF SAN JOSE cannot limit all potential sources of COVID-19 infection and cannot guarantee that I/my child will not become infected with COVID-19.

I voluntarily serve(s) the PARISH/SCHOOL AND DIOCESE OF SAN JOSE and I acknowledge that, by serving, I am/my child is increasing the risk of exposure to COVID-19. I/my child voluntarily assume full responsibility for any and all risks of illness or injury associated with my/my child’s exposure to COVID-19, or other infectious virus or disease, as well as from use of any protective equipment, including face coverings, that the PARISH/SCHOOL AND DIOCESE OF SAN JOSE may voluntarily provide to me/my child.

I hereby attest that:
• I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty of breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
• I have not traveled internationally within the last 14 days.
• I have not traveled to a highly impacted area within the United States of America in the last 14 days.
• I do not believe I have been exposed to someone with a suspected and/or confirmed case of COVID-19.
• I have not been diagnosed with COVID-19 and not yet cleared as non-contagious by state or local public health authorities.
• I am/is following all CDC recommended guidelines and limiting my/my child’s exposure to COVID-19.
• I agree that if I am exhibiting symptoms of illness such as cough, shortness of breath or difficulty of breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell, I will seek prompt medical attention, remain isolated and self-quarantine until I have/my child has been cleared by a medical professional.

I hereby release and agree to hold PARISH/SCHOOL AND DIOCESE OF SAN JOSE harmless from, and waive on behalf of myself/my child, my heirs, and any personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the PARISH/SCHOOL AND DIOCESE OF SAN JOSE, or that may otherwise arise in any way in connection with any Participant services I/my child provide(s) to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE.

I understand that this release discharges the PARISH/SCHOOL AND DIOCESE OF SAN JOSE from any liability or claim that I/my child, my heirs, or any personal representatives may have against the parish with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any Participant services provided to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE.

This liability waiver and release extends to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE together with its clergy, staff, and other Participants.

MEDICAL INFORMATION

Please provide information below.

Medical Plan Name and address*

Medical Plan Policy Number*

Medical Plan Phone*

Emergency Information

Emergency Contact(1) Name*

First Last

Emergency Contact(1) Phone*

Emergency Contact(2) Name*

First Last

Emergency Contact(2) Phone*

Type your name below as your electronic signature for your consent and participation activity waiver and photo/video release.*

Date of your consent and waiver.*