CATHOLIC DIOCESE OF EVANSVILLE PILGRIMAGE FOR LIFE YOUTH REGISTRATION PACKET In the pages that follow, you will find all of the documents necessary to allow your child to attend the Pilgrimage for Life to Washington, D.C. This packet has been designed to minimize the effort necessary to complete the various waivers and permissions required by the Diocese of Evansville: ALL FORMS IN THIS PACKET MUST BE COMPLETED AND RETURNED. Please note that the fields that follow are fillable. In other words, each field can be filled by checking it, then using your keyboard to type in the necessary information. As an example, click on the field that follows, and type your name . The field appeared blue, and your computer should have placed a cursor in the box that allowed you to easily type your name. If you were unable to do this, you may have to print these forms and fill them in by hand. It is important to note that you cannot save a completed form. You must complete the form and then print it—information entered into each field will not be saved. This means the forms must be completed at the same time rather than in stages. Finally, forms must be signed. Please do not type your name into the signature lines as this will not satisfy legal requirements for a signature. After completing and printing the forms, you must sign where indicated. Unsigned forms will not be recorded or registered. The following checklist will allow you to track your progress: ☐ Pilgrimage for Life Registration (pages one and two) ☐ Diocesan Event Waiver and Release (page three) ☐ Diocesan Medical Information Form (page four) Should you have any questions regarding these forms, please contact Steve Dabrowski ([email protected]). PILGRIMAGE FOR LIFE REGISTRATION Washington, D.C. January 21 - 25, 2015 ALL FORMS AND PAYMENT MUST BE RECEIVED BY NOVEMBER 28, 2014 Group/Parish/School Name: _ Group Leader’s Name: _ Participant Name: ______ Address: _ City: State: Zip: ______ Daytime phone: Evening phone: Cell phone of participant: Gender: ☐ Male ☐ Female DOB: If you are under 19, what is your age? Sweatshirt Size: ☐ Small ☐ Medium ☐ Large ☐ XLarge ☐ XXLarge Are you a group leader or chaperone? ☐ Yes ☐ No Answer if you will be 18 years or older (and out of high school) at the time of this trip: Have you completed the Diocesan Youth Protection Training? ☐ Yes ☐ No PRICE • $321 o o o o o per person, includes: Transportation Overnight accommodations at Holiday Inn Express Sweatshirt/lanyard/rain poncho Daily breakfast, one lunch, three dinners Tours of the Basillica of the National Shrine of the Immaculate Conception, St. Elizabeth Ann Seton National Shrine, and Gettysburg National Military Park. ROOMMATES Please list your roommate preferences. We will do our best to place you with your selected roommates but we may not be able to accommodate each request fully. 1. 2. 3. 4 Office Use Only _______ Date Received _______ Date Registered Online _______ Amount Paid _______ Scholarship _______ Waivers & Forms Complete _______ Entered Computer NOTE Participants’ individual payments must be made to their Group/Parish/School. Each Group/Parish/School will then issue one full payment in the form of a check for all participants from that Group/Parish/School. Full payment is due with online and hardcopy registrations on November 28, 2014. You will not be fully registered until all forms and waivers are completed and received along with full payment. In the event that maximum capacity is reached, we will create a “wait list” based on the date and time in which registrations are received. Buses will depart on Wednesday, January 21, 2015, from St. Ferdinand at approx. 8:15 p.m. (EST) following the Diocesan Mass for Life at 7 p.m. (EST). There will be various pick up points throughout the diocese – more information to come. We will return to the diocese early morning, Sunday, January 25, 2015. Due to Cancellation policies with the hotel and bus company we are unable to provide refunds for those unable to attend. Participants may receive up to a 90% refund if they are able to fill their spot with another person of the same age and sex AND they notify us on or before December 5, 2014. IMPORTANT ANY participant who is 18 years or older and out of high school at the time of the trip MUST complete the Diocesan Youth Protection Training and will need a background check. Please contact your parish Youth Protection Coordinator to make arrangements. No exceptions can be made to this policy. MORE INFORMATION www.evdio.org/pilgrimage-for-life.html RETURN OF REGISTRATION FORMS AND PAYMENTS: CHECKS (for groups): MAIL: Make payable to Catholic Diocese of Evansville – PFL (Include names of participants with check) Catholic Diocese of Evansville Pilgrimage for Life 4200 N. Kentucky Ave. P.O. Box 4169 Evansville, Indiana 47724-0169 DIOCESAN EVENT WAIVER AND RELEASE CATHOLIC DIOCESE OF EVANSVILLE (REV. 7/14) Youth’s Name: Parish/School/Program: Event: Pilgrimage for Life to Washington, D.C. Age: Grade: City: Date(s): 1/21/2015 – 1/25/2015 I/We, the parent(s)/guardian(s) of the above named youth, hereby give my/our approval for his/her participation in the above event. I/We assume all risks and hazards incidental to the conduct of the activities and transportation to and from the event. I/We do further hereby waive, release, absolve, indemnify, and hold harmless the Bishop of the Catholic Diocese of Evansville, Parish, _________________________Pastor, and any of their respective affiliates, successors, agents, employees, members, and representatives, adult sponsors, and other volunteers involved in the activities and transportation associated with the event from any and all claims, including claims of personal injury to my/our youth or property damage, under any theory of law (including negligence, but not reckless or intentional conduct) in any way resulting from or arising in connection with the activities and/or transportation to and from the event. It is understood and agreed that neither the Parish, the Catholic Diocese of Evansville, any respective affiliate, successor, agent, employee, member, representative, adult sponsor, nor other volunteer is the insurer of my child’s health and safety while he/she is at youth functions, engaged in supervised activities, including sports, or being transported in association with the event. I/We understand it to be my/our obligation to provide such insurance as I/we may desire to purchase to protect myself/ourselves and my/our child against the costs of sickness or injury. In case of emergency or serious illness, should the above-named child require medical treatment, and neither a parent nor the designated family physician can be contacted, consent is hereby granted for such medical treatment as may be considered necessary in the opinion of the attending physician. I UNDERSTAND THAT MY SIGNATURE RELIEVES DIOCESAN AND/OR PARISH PERSONNEL OF ANY AND ALL LIABILITY RELATED TO THE ADMINISTRATION OF ANY PRESCRIBED MEDICATION LISTED ON THE DIOCESAN MEDICAL INFORMATION FORM (INCLUDING OVER-THE-COUNTER DRUGS). Further, I/we acknowledge having read, or been made aware of the Diocesan Youth and/or Adult Codes of Conduct, the Diocesan Release for Media Recording, and the Diocesan Off-site Transportation Policy, and I/we agree to be bound by the terms and conditions set forth in those documents (copies available via www.evdio.org/diocesan-forms-for-oyaya.html). I acknowledge and understand that any action on behalf of my/our child/dependent that is inconsistent with the Diocesan Code of Conduct may result in appropriate disciplinary action as outlined in those documents. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. Parent/Guardian Printed Name: Signature: Date: 1 MEDICAL INFORMATION CATHOLIC DIOCESE OF EVANSVILLE (REV. 7/12) Youth's Name: Address: (Street) (City, State, Zip) Parent/Guardian to Call in Emergency: (Print Name) (Phone) (Print Name) (Phone) (Print Name) (Phone) If Parent/Guardian CANNOT be reached: Family Physician: Family Insurance Carrier: (Print Name) (Phone) Insurance Policy Number: Are parents living together: Yes. With whom does child live? Mother. No. Father. Other: Is anyone, by court order or decree, designated as the sole, custodial parent? If so, list: List anyone restrained from picking up child: I understand it is my responsibility to keep the youth minister informed about such matters and to provide copies of relevant court orders and decrees to officials. List any chronic or existing disease or medical problems (e.g. diabetes, asthma, epilepsy): List any medications your child is taking on a regular basis: Should it become necessary, please list any instructions for care of the above: Place "X" in box if it is NOT acceptable for your child to be provided over-thecounter medications (e.g., commonly used pain, allergy, or nausea medications). Parent/Guardian Signature Date