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Pilgrimage Registration

- Faith Formation

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- Participant's First Name REQUIRED Please fill out this field. Please enter valid data.
- Participant's Last Name REQUIRED Please fill out this field. Please enter valid data.
- Participant's Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Parent/Emergency Contact's First and Last Name REQUIRED Please fill out this field. Please enter valid data.
- Parent/Emergency Contact's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent/Emergency Contact's Email REQUIRED Please fill out this field. Please enter an email address.
- Doctor's Name REQUIRED Please fill out this field. Please enter valid data.
- Doctor's Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Insurance Company Name Please enter valid data.
- Insurance Policy Number Please enter valid data.
- Participant's Allergies (Including meds and food) REQUIRED Please fill out this field.
- Participant's Chronic Medical Problems (e.g. diabetes, etc.) REQUIRED Please fill out this field.
- I request permission for myself/my child to attend the High School Pilgrimage to be held by St. John Paul II Parish. I understand this event will take place under the guidance and supervision of responsible employees/volunteers from the diocese and if needed, give permission for myself/my child to be evaluated, diagnosed, treated/medicated in accordance with standard medical practice by licensed medical personnel. I relieve the diocese and volunteer leaders of all responsibility and consequences that may arise because of this treatment. I will not hold the diocese or representatives associated with this event responsible in the event of injury. If I cannot be reached in case of an emergency I give permission for the parish group leader to act on my behalf. Further, I agree to accept any and all financial responsibility because of scheduling such care.
  
  I/my child agrees to abide by all the rules as outlined in the Code of Behavior/Ethics. The diocese will not be liable if myself/my child fails to cooperate with said rules and any infractions may result in immediate dismissal from this event. I will accept responsibility for costs for immediate transportation home. I understand that I am legally responsible for the behavior of myself/my child.
  
  I hereby grant to the diocese and my parish consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child’s name, voice, image, and/or likeness that arises from my/his/her participation in this event, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at the parish’s sole discretion.
  I Agree Please select this field.
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