March for Life Pilgrimage –ADULT $325.00
ARCHKCK Registration, Permission & Liability Waiver and Health
Archdiocese of Kansas City in Kansas
Jan 20-24,2015 Washington DC
Name______Date of Birth______(mm/dd/yy)
Street Address ______
City, State and ZIP ______
Sex______SS#______Parish______
Are you in general good health and able to participate in general activities? Yes_____ No______
If not, please indicate special circumstances and situations here: ______
______
Date of most recent physical examination by licensed medical doctor. Date______
Name of family physician or clinic ______
Street Address______Phone______
City, State and ZIP ______
Are all immunizations up to date: Yes______No______Date of last tetanus booster______
If any are not please list them______
Medications: Please list medications and frequency.______
______
If you will be bringing any over the counter medications, please list them______
______
Please list any special dietary needs:______
______
Have you had any operations or serious injuries (please list and date): ______
______
Do you have any medical limitations or needs that we need to be aware of? Please describe. ______
______
Have you completed:
- Virtus Training
- Archdiocesan Policies (Child Protection, Code of Ethical Standards & Harassment Policies)
- Background Check through your local coordinator
YES______NO______
All of the above are required in order to be a chaperone for any youth events in the Archdiocese or if you are a young adult over the age of 18 and not attending high school.
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Page 2- Archdiocesan Permission & Liability Waiver and Health Form
PLEASE NOTE THAT THREE SIGNATURES ARE REQUIRED ON THIS PAGE
In signing this health form, I hereby certify that the above information is correct and give permission for the release of medical records to an attending physician in case of illness.
In case of medical emergency, I hereby give permission to the physician selected by the NCYC or Archdiocese to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for me.
#1 Signature______Date______
Full Address______
streetcitystateZIP
Phone #’s you may reach me during the March for Life Pilgrimage: ______
Relative/friend to contact in case you can not reach me ______Phone#______
Health Insurance Company______
Health Insurance Policy #______
Primary Health Insurance Holder Name and Social Security #______
A photocopy of the Primary Health Insurance card MUST be submitted with this form.
I request that I be allowed to participate in, and be transported to and from, the March for Life Pilgrimage, Jan 23-27, 2013 in Washington DC. I hereby release and indemnify the Archdiocese of Kansas City in Kansas, its staff, and volunteers from any liability arising from claims of any kind or nature whatsoever from my participation in this program.
#2Signature ______Date______
During the March for Life Pilgrimage, I give my permission to the Archdiocese of Kansas City in Kansas to take photographs and video of me to be used for future promotional items.
#3Signature ______Date______
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