2025 Adult Retreat Form Adult Retreat Dates: Saturday, June 7, 2025 - Saturday, June 14, 2025. Please fill one form per camper. Application without any of the folllowing will not be accepted. Registration Form (included with this online submission) Payment (included with this online submission) Consent (included with this online submission) Copy of Health Insurance (can upload with this online submission) Completed Medical Clearance Form (can upload with this online submission) Online registration is required. Email Mallikaben at mallikampatel29@gmail.com OR Kaminiben at coreresusa@gmail.com for any questions.Camper InformationRetreat Member or Correspondence Email(Required) Enter Email Confirm Email Retreat Member Name(Required) First Last Retreat Member Birth Date(Required) MM slash DD slash YYYY Retreat Member or Correspondence Mobile Phone #(Required)Retreat Member Home Phone #Retreat Member Gender(Required) Male Female Retreat Member Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Retreat Member Health Insurance Carrier/Plan(Required)Enter N/A if no insuranceRetreat Member Health Insurance ID(Required)Enter N/A if no insuranceRetreat Member Health Insurance Group #(Required)Enter N/A if no insuranceRetreat Member Health Insurance Subscriber Name(Required)Enter N/A if no insuranceAttach a copy of the front of the insurance id card(Required)Max. file size: 5 MB.Attach a copy of the back of the insurance id card(Required)Max. file size: 5 MB.Atatch Physician signed Medical Clearance Form(Required)Max. file size: 5 MB.T-Shirt Size(Required) S M L XL XXL Emergency Contact Name(Required) First Last Emergency Contact Relationship(Required)Emergency Contact Phone #(Required)Payment InformationDonation Amount per Camper - $401.00. Non-registered persons are not allowed in any registered camper rooms.Retreat Member Fees Price: Would like a Private Room?(Required)Total due for Private Room is $1604. If you and your spouse is using the private room, the $1604 fee is needed once only. Fill only one form in this case and write your spouse's information in the comment section below. Yes No Private Room Donation Price: Total Amount Credit Card(Required)Card Details Cardholder Name Consent(Required)- I consent to stay at Vraj Retreat during the period indicated on registration form. - I understand that I am choosing to stay and participate with other members of the program during all the activities. - I understand that this gathering is a very informal family type of gathering, and that the institution does not assume any legal responsibility of the attendee. - I hereby release PMVS and its associates, workers and volunteers of any liability arising from any accidents or injuries that may occur to me while attending the gathering. - I grant permission to give all necessary treatment or urgent care to me, if I am unconscious or not capable of making decisions. - I understand that I am liable for full payment of all medical and related expenses during my stay at Vraj. Vraj is not liable for payment of any medical and/or any other expenses. - Vraj facilities may have been used for food preparation with peanuts, tree nuts, soy, milk and wheat. - Vraj will not be able to provide quarantined facilities or meals to Vaishnavs with specific dietary requirements. - I understand that the Vraj facility is located in the rural area of Wayne Township, PA. In case of emergency it may take up to 45 minutes to reach the Hospital, after calling 911. - Even though Vaishnavs with severe food allergies may be trained to administer Epipen, they may not reach the Hospital in less than 45 minutes. - I understand that Vraj volunteers are not liable if they are not able to provide adequate life saving First-aid service while waiting for 911 to respond. - I understand that a medically trained person is not available at Vraj. I am able to take care of my health issues and able to take regular and emergency medicine without any assistance. - Adult retreat committee may decline my registration based on the review of documents and deems to be concerned about the well-being of myself. - I am physically independent for daily activity and capable of walking around in Vraj Campus without difficulty. I am able to climb stairs. Donation per private room is $ 1404, if available. - I understand that persons not registered in the program are not allowed in any registered person’s room. Maximum four registered members are allowed in any room. I agree to the privacy policy.CommentsAdd any comments or information important for camp administration to know.Retreat Member Signature(Required) First Last Date(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ