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San Juan Mission - Adult

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  I, (Name), REQUIRED Please fill out this field. Please enter valid data.
  
  do hereby release, hold harmless and discharge the Archdiocese of Galveston-Houston, Saint Mary of the Expectation Catholic Church, its staff and volunteers from any and all liability, claim, loss, damage, cost, or expense arising from my participation in the San Juan Mission trip from June 4th-June 10th, 2023, in San Juan, TX and the surrounding area. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
  
  Participant
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  Address Please enter valid data.
  
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  Zip Please enter a zip code.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  T-shirt Size REQUIRED Please fill out this field.
  
  Physician's Name Please enter valid data.
  
  Physician's Phone Number Maximum 20 characters Please enter a phone number.
  
  (The following request is pertinent information if you are rendered unconscious)
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Date of Last Tetanus Shot Please enter a date.
  
  Please list ALL medical conditions / allergies / special health information including bouts with depression and anxiety:
  
  Please list ALL medications (prescription or non-prescription) you would like us to be aware of:
  
  Insurance Information
  
  Do you currently have Medical Insurance? REQUIRED Please fill out this field.
  
  Insurance Company Please enter valid data.
  
  Policy in Name of Please enter valid data.
  
  Policy Number Please enter valid data.
  
  Group Number Please enter valid data.
  
  In the event that participant does not have insurance, payment in full for medical care becomes the responsibility of the patient.
  
  Name of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Signature REQUIRED Please fill out this field. Please enter a date.
  
  In signing the line above I agree to abide by any/all policies and rules established for this event/activity. Should I not be able to maintain the guidelines and expectations of the adult chaperones/young adult assistants, I understand that there will be consequences for my actions, which could include being asked to leave the event.
  
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- Contact Us
  
  David Harley
  
  Director of Youth Ministry
  
  281-332-3031 ext. 116
  david.harleysaintmcc.org