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$100.00 Dep. Per person due Dec.

21, 2009
Final Payment due Friday Jan. 11, 2010
Mail to:
March for Life Pilgrimage - ADULT Archdiocese of Kansas City in Kansas
Archdiocesan Registration, Permission & Liability Waiver and Health Office of Evangelization/Catholic Formation of Youth
Form 12615 Parallel Parkway
Archdiocese of Kansas City in Kansas Kansas City, Kansas 66109
Jan 20-23, 2010 Washington DC Fax 913-721-1577 Amount received: _____________
• $260.00 Holiday Inn Central Washington DC
1501 Rhode Island Ave. NW Washington DC 20005
Name_______________________________________________________ Date of Birth_________________ (mm/dd/yy)

Street Address ____________________________________________________________________________________

City, State and ZIP _________________________________________________________________________________

Sex_______ SS#____________________ Parish ___________________________ Phone ___________________

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 ________________________________________________________________________________

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Are all immunizations up to date: Yes________ No________ Date of last tetanus booster_____________________
If any are not please list them________________________________________________________________________

Medications: Please list medications you are taking with frequency and dosage. _________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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 injury (please list and date): ___________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Do you have any medical limitations or needs that we need to be aware of? Please describe. _______________________
__________________________________________________________________________________________________

Do you have any other limitations or needs (learning styles, family situations, custody arrangements, etc) that we need to
be aware of? If yes, please describe. ____________________________________________________________________
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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 Archdiocese to hospitalize, secure proper
treatment for and to order injection, anesthesia or surgery for me.

#1 Signature________________________________________________________________ Date____________________

Full Address_________________________________________________________________________________________________
street city state ZIP

Relative/friend to contact in case of an emergency ______________________________________ 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 20-23, 2010 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.

#2 Signature _______________________________________________________________ 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.
#3 Signature _______________________________________________________________ Date_________________________

NOTARY (REQUIRED)
City/County of _________________________________________________; State of ______________________________________
On this __________ day of ______________________________________, 20__, before me personally appeared the adult names
hereinabove, who is personally known to me or produced positive identification, and who executed the foregoing Liability Waiver and
Permission Form, and acknowledged that he/she executed the same as his/her free act and deed.

Signature of Notary Public: __________________________________


[Notorial Seal] My commission expires: ____________________________________

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