St. Aloysius Church

Leonardtown, MD

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Register for The Journey Pilrimage

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  Participant Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  2026-2027 Grade REQUIRED Please fill out this field.
  
  Gender Male Female
  
  Cell Phone Number Maximum 20 characters Please enter a phone number.
  
  Parent or Guardian Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Home Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  I, [above-named Parent or Guardian] grant permission for my child, [above-named Minor Participant] to participate in this activity or event that requires transportation to a location away from the parish site. Except for activities conducted through a third-party provider, this activity will take place under the guidance and direction of parish employees and/or volunteers from St. Aloysius Church and other parishes of the Archdicese of Washington.
  
  A brief description of the activity/event (which may involve high-risk/adventure activities) follows:
  
  Type of activity/event: The Journey Pilgrimage to St. Clement’s Island
  Destination of event: St. Clement’s Island, Colton’s Point, Maryland
  Orgnization in charge: St. Aloysius Church, Leonardtown, MD
  Mode of transportation to and from event: Boat
  
  As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). On behalf of myself and the participant, I hereby fully release, and waive any and all claims against, the Archdiocese of Washington, its parishes, directors, employees, agents, chaperones, and representatives associated with the activity/event (collectively, “Archdiocese”), as set forth below in more detail.
  
  I understand that this activity/event may involve high-risk activities, with an increased risk of personal injury. I further understand that a separate, location-specific release and liability form(s) (“Location-Specific Release”) may be required by the third-party provider(s) of the high-risk activities (“Third-Party Provider”). I agree that it is my obligation to read the Location-Specific Release and carefully consider the risks involved before signing.
  
  With appreciation of the dangers and risks associated with this activity/event and all related activities, on my own behalf and on behalf of the participant, I hereby fully and completely release and waive any and all claims, including—but not limited to—those for personal injury, death, or loss, that may arise against the Archdiocese of Washington and I hereby further agree that the full scope of the Location-Specific Release’s waiver and release language shall also encompass any potential claims against the Archdiocese of Washington related to this activity/event, such that the Archdiocese of Washington is released from any and all claims at least to the same extent as the Third-Party Provider.
  
  On behalf of myself and on behalf of the participant, I hereby fully and completely release and waive any claims against the Archdiocese relating to and/or arising out of the activity/event, to the fullest extent allowed by law.
  
  I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns, to hold harmless and defend St. Aloysius Church, its officers, directors, employees and agents, and the Archdiocese of Washington, its employees and agents, chaperones, and representatives associated with the event, from any claim arising from or in connection with my child attending the activity/event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Washington, its employees and agents and chaperones, or representatives associated with the event, for reasonable attorneys’ fees and expenses which may incur in any action brought against one or more of them as a result of such injury or damage.
  
  By signing or typing your name below, I represent and warrant that I am the parent or legal guardian of the participant and have authority to sign this consent, release, and waiver.
  I have read and agree to the Consent, Release, and Liability Waiver Please select this field.
  
  Medical Information
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)
  
  Emergency Medical Information
  
  In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
  
  In the event of an emergency, if you are unable to reach me at the above numbers, contact:
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Relationship to Participant Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Family Doctor
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Medical Insurance
  
  Family Health Plan Carrier Please enter valid data.
  
  Policy Number Please enter valid data.
  
  Medications
  
  My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:
  
  Medications & Instructions
  
  No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.
  
  I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate. Yes No
  
  Specific Medical Information
  
  Allergic reactions (medications, foods, plants, insects, etc.): Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
  
  Does child have a medically prescribed diet? Please enter valid data.
  
  Any physical limitations? Please enter valid data.
  
  Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting? Please enter valid data.
  
  Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
  
  You should be aware of these special medical conditions of my child: Please enter valid data.
  
  Signature (Typed)
  Typing your name here constitutes your legal signature
  Please enter valid data.
  
  Registration Fee65.0
  
  Total:
  
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Register for The Journey Pilrimage

Medical Information