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Medical and Consent Form
The Pilgrimage, Washington D.C.
With Broad Street Presbyterian Church
June 9-14, 2019

Broad Street Presbyterian Consent

I/We do hereby give permission for my/our child to attend and participate in The Pilgrimage summer trip to Church of the Pilgrims, Washington, D.C. from June 9-14, 2019.

In the event of an emergency, I/we do also hereby give permission to the adult leaders as representatives of Broad Street Presbyterian Church to act in my/our behalf to consent to any medical treatment or hospitalization deemed necessary by the leaders and a licensed physician or emergency team.  I/We agree to be liable to any and all costs involved in such emergency treatment.  I/We release and discharge Broad Street Presbyterian Church and/or representatives involved in this activity from any liability in exercising this permission.  The health information on this form is true to the best of my/our knowledge and I/we give permission to the leaders to dispense medications as directed and indicated on this form to my child.

Pilgrimage Liability Release Form

In consideration of the acceptance of my registration, for myself, administrators, and assignees do hereby forever release and discharge The Pilgrimage, of Church of the Pilgrims (PCUSA), and all other affiliates, sponsors, and subsidiaries of all claims and damages, demand and actions whatsoever in any manner arising out of my participation in The Pilgrimage programs. I attest and verify that I have full knowledge of the risks involved in this event, and I am physically fit to participate in Pilgrimage programs. Further, I hereby grant full permission to any and all of the foregoing pictures, recordings, and any other record of this event for legitimate purposes (i.e. Pilgrimage web site) without compensation or renumeration.

Parent or Gaurdian's Signature:

Participant's Signature (both adult and youth):

Today's Date: March 21, 2019

 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Medical Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health or physical limitations of the participant:

Gender *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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