Liên Hoa Buddhist Temple

Registration Form for The 201 9 Bodhi Youth Camp Summer Retreat

Please fill out separated individual form for each participant.

Participant’s Name : Dharma Name:

DOB :Age: Gender:

Address :

Phone : Cell: Home:

Email :

Have you participated in any summer camp or meditation retreats before?
Please share with details.

Have you practiced meditation or exposed to meditation before?
If yes, how long have you been practicing? Please share with details.

Name of parents or guardian:

Phone : Cell: Home:

Email :

Name of emergency contact person:

Phone : Relationship with the participant:

Is there any health/medical concerns? Is the participant taking any medications? Allergy? Please attach any relevant medical/health record if it is important for the camp coordinator to know.

Hospital: Phone :

Agreement of the camp participant and parents/guardian :

By signing below, I agree for the above participant’s name to participate in this 2019 Youth Camp Summer Retreat at Lien Hoa Buddhist Temple, MN from August 2-4, 2019.

1. I will diligently follow the camp rules and regulations.

2. I will not create difficulty or have Lien Hoa Buddhist Temple hold liability for anything if unfortunate incidents such as injury or loss happen during the camp.

3. Parents/guardian will bring the participant home right away if the participant fails to follow the rules and regulations of this summer camp retreat.

4. Parents/guardian will bring the participant to the camp and will pick up the participant from the camp promptly on time.

*** Please accept and allow my child to participate in this 2019 Youth Camp Summer Retreat at Lien Hoa Buddhist Temple. I have reviewed this summer camp retreat program and its rules and regulations in details with my child, which we agreed to follow.

Bottom of Form

Parent’s or Guardian’s signature:


Participant’s Signature :



The 201 9 Bodhi Youth Camp Summer Retreat

Camp Guidelines:

To ensure every camp participant has a safe and effective learning environment as well as having a good time at the camp, we request that every camp participant diligently follow these camp guidelines at the Lien Hoa Buddhist Temple:

1. Always being respectful to the teachers, camp counselors, volunteers and friends at the camp.

2. Wear appropriate clothing at the temple. No sleeveless top. No mini-shorts. No swimsuits.

3. Live in harmony among others at the camp. Interact calmly and nicely with others. Practice kindness. Practice being humble and content with what is.

4. Avoid saying or doing anything that could potentially hurt other people’s feelings.

5. Not bringing guns, alcohol products, tobacco products, or any other illicit drugs to the temple campus.

6. Be responsible for your own personal belongings.

7. Do not leave the temple campus without having permission from teachers or camp counselors.

8. If a camp participant engages in unlawful actions, or demonstrates violent behaviors that cause harms to self or others, or exhibits disruptive manners that negatively effect the camp, his/her parent or guardian will be contacted and will be responsible to bring the camp participant home immediately.

Waiver of Liability:

I certify that I am the parent/legal guardian for this child (camp participant). I understand that my child’s participation in this summer camp at Lien Hoa Buddhist Temple may expose my child to risks of property damage and bodily or personal injury, including injury that may be fatal. I knowingly and freely assume, on behalf of my child, any and all such risks and voluntarily participate in this camp. I understand that it is my responsibility, as the participant’s parent, to allow my child to engage only in those activities that are appropriate, and I will communicate this clearly with the camp counselors and staff.

If my child has certain medical conditions that require urgent care, I give permission for the camp counselors or staff to provide the most appropriate immediate care for my child at that time or make emergency decisions for my child with their best ability, including calling Emergency Medical Services, to ensure my child’s safety and wellbeing.

I will hold forever harmless and will not take legal action against the Lien Hoa Buddhist Temple for any claim for damages arising or growing out of my child’s participation in this activity whether caused by negligence or otherwise.

Media Release Waiver

As parent/guardian, I WILL NOT / WILL grant permission for the Lien Hoa Buddhist Temple to use a camper’s photograph or other media such as videos for display on temple’s website, Facebook page, or inclusion in Camp publications. I understand that Lien Hoa Buddhist Temple respects the wishes of anyone who prefers not to grant such permission.

By signing below, camp participant and his/her parent/guardian agree to follow the above camp guidelines and waivers.

Signature of camper: Date:

Signature of parent/guardian: Date:


***Please turn in your registration form prior to July 25th, 2019. You can contact venerable Đức Thành, (714) 343-5562, with any questions or concerns.