CLERGY/MILITARY CHAPLAIN APPLICATION FORM

Transcription

1 CLERGY/MILITARY CHAPLAIN APPLICATION FORM Application for the Warriors to Lourdes Pilgrimage, May 2016 Applicants are encouraged to complete this form electronically for better legibility; completed applications can then be submitted WITH the applicant s electronic signature to Lourdes@kofc.org or via U.S. mail. If you are unable to fill out this application electronically, please print the application and fill out each question by hand. The completed form should then be mailed to the following address: Knights of Columbus Attn: 2016 AMS-KofC Warriors to Lourdes Pilgrimage 78 Meadow St. New Haven, CT Please note: This application must be thoroughly, accurately and neatly completed. Completed and signed applications along with supporting materials must be submitted no later than 15 January All applications received after this date will be placed on a wait list. PERSONAL INFORMATION Full Legal Name (as it appears on your passport): Preferred name (for your PMI credentials): Gender: Male Female DOB: Service Affiliation (if applicable): Army Marines Air Force Navy Coast Guard Current Status (if applicable): Active Retired Separated Honorably/Medically Discharged Military Rank: Religious Affiliation: Clerical Title: Current Address (point of origin for travel to Lourdes): City: State: ZIP: Telephone (H): - - (W): - - (Cell): - - address: Be advised that most pilgrimage information updates will be sent via . Provide an address that is frequently checked. Marital Status: Name of Spouse (if married): 1

2 How did you learn about the AMS-KofC Warriors to Lourdes pilgrimage? Through my WTU command Through the Archdiocese for Military Services Through a Military and/or KofC Chaplain If so, please provide name: Through a Knights of Columbus council Through the Knights of Columbus website Through Knights of Columbus social media sites Through a past WTL pilgrim Other Please briefly share what prompted you to apply for participation on this pilgrimage. COMPANION INFORMATION Are you traveling with a spouse, adult relative or adult friend? Yes No If yes, who? Name: Current Address: City: State: ZIP: Telephone (H): - - (W): - - (Cell): Your relationship to this person? Companions traveling with a military chaplain or clergy member must complete and submit the Companion Application Form. ADOLESCENT AND/OR CHILD COMPANION INFORMATION Are you traveling with or accompanying any other pilgrim(s) between the age of 14 and 18? Yes No Are you travelling with children under the age of 14? Yes No If yes to either of the above questions, please provide the name of each child. Specific their ages by May 2016, and note your relationship to each child: 2

3 EMERGENCY CONTACT INFORMATION Please provide the name of a family member or other individual to be contacted in case of an emergency. Your emergency contact should NOT be traveling on the pilgrimage. Name: Relationship: Home Address: City: State: ZIP: Telephone (H): - - (W): - - (Cell): TRAVEL INFORMATION NOTE: Passports must be valid through 23 November 2016 (6 months post return date). Name: (Print name EXACTLY as it appears on your passport) Passport Number: Country of Issue: Passport Expiration Date: (MM/DD/YYYY) Date of Birth: (MM/DD/YYYY) Alien Registration Number (if applicable): If you are in the process of applying for a passport, please indicate the approximate date you expect to receive it: (MM/DD/YYYY) 3

4 TRANSPORTATION Will you travel on the AMS-KofC-arranged flights from the US to Lourdes, and return? Yes No Will you travel on the AMS-KofC-arranged bus transport from Kaiserslautern, Germany, and return? Yes No Will you be arranging your own travel from the US? Yes No Will you be arranging your own travel from Europe? Yes No If you are flying from the US, will you require special dietary accommodations on the flight? Yes No If yes, please specify special meal request and/or dietary requirements: HOTEL ROOM ASSIGNMENTS Clergy and Military Chaplains will be assigned single rooms, unless they are traveling with a spouse. Spouses wishing to travel on the Warriors to Lourdes Pilgrimage must complete and submit a separate application form. Are you sharing a double room with a spouse? Yes No If yes, please provide your spouse s name: SHIRT SIZE Please circle one Women s S M L XL XXL XXXL Men s (Please Note: Men s Van Heusen Shirts Run Large) S M L XL XXL XXXL MEDICAL INFORMATION Have you been under a physician's care at any time in the last six months? Yes No Name of your physician: Telephone (H): - - (W): - - (Cell): - - Please list the conditions for which you receive care; also list the prescribed treatments you receive for these conditions (add additional information on a separate paper, if necessary). If applicable, please list all of your medications and include condition, dosage and schedule. Please attach a listing in this format if additional space is necessary. Important note: Medical marijuana is prohibited on any international flight and is illegal in France. 4

5 Medication Condition Dosage Schedule Do you have any food and/or drug allergies? Yes No If yes, please explain: Do you have any limitations in performing your own personal activities of daily living? Yes No If yes, please explain: What is your current height, weight and age? Height: Weight: Age: PHYSICAL CAPABILITIES Can you walk and stand for up to two hours at a time? Yes No Are you under a doctor s care for a physical ailment or chronic medical condition? Yes No If yes, please explain: Are there any medical or physical factors that would prevent you from participating fully in all activities throughout the duration of the pilgrimage? Yes No CHOIR If yes, please explain: PLEASE NOTE: The choir is comprised of members of the AMS-KofC pilgrimage. The choir rehearses once or twice during the pilgrimage, and sings at all of the masses. Do you wish to be a member of the choir? Yes No CLERGY/MILITARY CHAPLAIN ACCEPTANCE ACKNOWLEDGEMENT Members of the Clergy / Military Chaplains accepted to participate in the 2016 Pilgrimage will be asked to acknowledge their acceptance in writing. My signature below indicates that I understand the rigors of the trip, that I have truthfully completed this application, and that I have fully informed the AMS and the KofC, by way of this application, of any existing medical condition and my willingness to participate as a member of clergy or military chaplain. Printed Name: Signature: Date: 5

6 CLERGY/MILITARY CHAPLAIN PAYMENT FORM Please complete this payment page for EACH applicant. Payments may be combined for multiple travelers. Full Name: Lourdes +Travel As a member of the clergy / military chaplain, the cost of your trip, which includes (and is limited to) AMS-KofC-arranged travel to and from Lourdes, AMS-KofC-arranged accommodations and full meal plan, is covered by Knights of Columbus Charities, Inc. no charge (Double Occupancy Room - if traveling with a spouse) no charge (Single Occupancy Room) Payment The total cost for my trip is Total Amount Enclosed: (Due with application by 15 January 2016) $ $ Please make checks payable to: Knights of Columbus Charities, Inc. Please mail your payment in full no later than 15 January 2016 to the following address: Knights of Columbus Attn: 2016 AMS-KofC Warriors to Lourdes Pilgrimage 78 Meadow St. New Haven, CT *NOTE FOR THOSE TRAVELLING BY AIR FROM THE U.S. ON AMS-KofC ARRANGED TRAVEL: If you must cancel your trip after the flight cancellation deadline of 12 April 2016 for medical reasons, you must provide a doctor s note. The flight cancellation deadline for those flying out of Houston and Seattle is 31 January 2016 as these flights will be booked individually and not as a group block. *The same deadlines apply to those looking to make changes to their flight itineraries. Individuals making itinerary changes that result in an increase in flight fare must absorb the difference in cost. 6

7 Pilgrimage Release of All Liability Agreement Archdiocese for the Military Services (AMS) and Knights of Columbus (KofC) 2016 Warriors to Lourdes Pilgrimage AGREEMENT I acknowledge that I am voluntarily applying to attend the 2016 AMS-KofC Warriors to Lourdes Pilgrimage (hereafter referred to as the Pilgrimage ) that will be conducted in Lourdes, France, May 17-23, 2016, and to engage in all scheduled activities associated with the Pilgrimage. In the event that I am accepted and choose to attend the 2016 Warriors to Lourdes Pilgrimage as a warrior pilgrim, I am aware that participating in the Pilgrimage and its activities involves a risk for injury to my person and my property. I voluntarily accept all risk of personal injury and property damage arising from my attendance and participation in the Pilgrimage. I understand that neither the Archdiocese for the Military Services (AMS) nor the Knights of Columbus (KofC) undertakes responsibility for my medical care during the Pilgrimage, nor while traveling to or from the Pilgrimage. As lawful consideration for being permitted to attend the Pilgrimage and to participate in its activities, I hereby agree that I, my heirs, my personal representatives, and my assigns will not make a claim against nor sue the AMS or the KofC, their officers, directors, medical and non-medical volunteers, or agents for any injury or damage arising from negligence or other acts, however caused. In addition, I hereby release, discharge and hold harmless the AMS or the KofC, their officers, directors, employees, medical and non-medical volunteers, or agents from all actions, claims (including malpractice claims) or demands that I, my heirs, personal representatives, or assigns may have for injuries or property damage or any other loss or damage of any kind, including without limitation all consequential damage resulting from my attending the Pilgrimage or participating in its activities. I agree that this release includes injury or damage caused in whole or part by the negligence of the AMS or the KofC, their officers, directors, medical and nonmedical volunteers, or agents. This Pilgrimage Release of All Liability Agreement does not relieve the AMS or the KofC, their officers, directors, volunteers or agents from liability arising from acts of wanton and willful misconduct. This agreement applies to all travel in connection with the Pilgrimage (and travel to and from Lourdes, France), whether by aircraft, railroad, motor coach, bus, private car, boat or any other means of transportation. It also applies to any loss or damage which directly or indirectly results from acts of God, acts of government or state authorities de jure or de facto, including but not limited to war, civil disturbances, strikes, riots, terrorism, theft, acts of violence, epidemics or any other causes beyond the control of the AMS or the KofC. This agreement is for the benefit of the AMS and the KofC, their officers, directors, employees, volunteers (medical and non-medical) and agents. Third parties, such as common carriers and hotels, are not released from their liability for their acts by this Agreement. I am aware that there may be limits upon the liability of such third parties arising from international conventions or other laws, and that I may be able to obtain additional protection by purchasing traveler s insurance from a private company such insurance is not affected by those limitations of liability. I have carefully read this agreement. I understand that it is a complete release of liability and that I am making a promise to not sue or to make a claim (to include malpractice claims against Pilgrimage medical volunteers). I am aware that it is a contract between the AMS, the KofC, and me. Printed Name (as it appears on passport): Signature: Date: 7

8 KNIGHTS OF COLUMBUS AUDIO/PHOTO/VIDEO MEDIA RELEASE FORM (Ages 18 and up) I (print name), grant permission to the Knights of Columbus and its agents or employees to use photographs and/or video and audio taken of me in the event that I am accepted and choose to attend the 2016 Warriors to Lourdes Pilgrimage. These images may be used in educational, promotional and documentary materials such as Public Service Announcements, Video Documentaries, Promotional Web Videos, and both printed and online newsletters. Furthermore, I authorize the use of my image, likeness, and voice for all program promotion, materials, and any other purposes in connection with the program deemed appropriate and necessary by the Knights of Columbus Charities. I hereby agree to release, defend, and hold harmless the Knights of Columbus and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution. I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. Signature Date KNIGHTS OF COLUMBUS AUDIO/PHOTO/VIDEO MEDIA RELEASE FORM (For minors under the age of 18) I (printed name of parent of guardian), grant permission to the Knights of Columbus and its agents or employees to use photographs and/or video and audio taken of the child/children in my care in the event that we are accepted and choose to attend the 2016 Warriors to Lourdes Pilgrimage. These images may be used in educational, promotional and documentary materials such as Public Service Announcements, Video Documentaries, Promotional Web Videos, and both printed and online newsletters. Furthermore, I authorize the use of my child s image, likeness, and voice for all program promotion, materials, and any other purposes in connection with the program deemed appropriate and necessary by the Knights of Columbus Charities. I hereby agree to release, defend, and hold harmless the Knights of Columbus and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution. I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. Signature of Parent or Legal Guardian Date 8