Jonathan Daniels Youth Pilgrimage: Youth Registration

Jonathan Daniels Youth Pilgrimage: Youth Registration

Youth Participant Registration
Jonathan Daniels was an Episcopal seminarian martyred in August of 1965. The Jonathan Daniels pilgrimage has become a fixture for many and a reminder that the equality for which he gave his life is a continuing sacrifice. The Jonathan Daniels Youth Pilgrimage is a weekend of service and remembrance for youth grades 9th-12th grade. We will gather at Episcopal Church of the Ascension (315 Clanton Avenue Montgomery, AL 36104), with registration from 5:30-6:30p, on August 11th. The weekend will conclude on August 13th around 2:00p.

When: August 11-13, 2023
Where: Episcopal Church of the Ascension (315 Clanton Avenue, Montgomery, AL 36104)

There will be a registration fee of $25, cash or check, for all participants. Makes check payable to the Episcopal Diocese of Alabama ATTN: Jonathan Daniels Youth Pilgrimage. If cost is a hinderance, scholarships are available. For any question or concerns, contact Breanna Mitchell bmitchell@dioala.org.

Transportation is not provided.

Youth ministers, or an adult chaperone, are required to be present with their youth group.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birthdate

MonthDayYear
Date
Parent/Guardian First and Last Name
Parent/Guardian Phone Number
Parent/Guardian Email Address
Do you attend an Episcopal church?
What church do you attend?
Church membership is not a requirement
Are you registering as part of a youth group?

YesNo
If yes, what youth group will be attending with?
If no, please indicate with "N/A".
I will...

Lodge at Church of the AscensionLodge at a location off-site
I will...

Be present for the entire eventOnly be participating for the Saturday events
Dietary Restrictions and/or allergies

Gluten-FreeVegetarianVeganNo dietary restriction/allergiesOther
List food allergies
Type "N/A" if there are no dietary restrictions/allergies
Short Answer Questions
What do you hope to learn from the weekend pilgrimage?
Tell us a brief story about an experience that helped shape your understanding of race.
Share one way you have committed to respond to racial injustice. What is one way you are working against racism, "big" or "small"?
Medical Information
Medication(s) at Event
Name of Insurer
Name on Insurance Card
Policy Number
Group Number
Youth Release

A parent/guardian must be present when filling out this portion of the application. Please have them sign the consent forms below. Your application is not valid otherwise.
Covenant of Common Life

I agree to live by the standards set for the event. I understand there is no use or possession of alcohol, tobacco products, illegal drugs, or weapons of any kind. I understand inappropriate sexual behavior is not tolerated. In order to respect all participants' privacy, at no time may a male enter a female housing site or a female enter a male housing site. If I choose to violate these standards or jeopardize the work of this ministry or am knowingly in the presence of others violating these standards, I will be sent home immediately at my own expense. In an effort to foster an inclusive atmosphere, common areas for males and females to gather will be defined.
Covenant of Common Life Signature (signed by youth participant)

Clear
Parent/Guardian Agreement

I give permission for my minor child to attend and participate in the events sponsored by the Episcopal Diocese of Alabama. I do hereby, for myself and for my child, release the Episcopal Diocese of Alabama, its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from the Jonathan Daniels Youth Pilgrimage activities. I give permission to Episcopal Diocese of Alabama, without limitation or obligation to use photographs, film footage, or tape recordings which may include camper’s image or voice for purposes of promoting or interpreting its programs and release the Episcopal Diocese of Alabama from any claim of liability for that use. I give permission to the Episcopal Diocese of Alabama, without limitation or obligation to use photographs, film footage, or tape recordings which may include camper’s image or voice for purposes of promoting or interpreting its programs and release the Episcopal Diocese of Alabama from any claim of liability for that use.
Parent/Guardian Agreement Signature

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Parental/Guardian Medical Consent

I hereby authorize all the adult volunteers & medical staff of the event, to seek and consent to any medical, surgical or dental treatment for my child as needed, to be rendered under the general or special supervision and on the advice of any licensed physician or dentist; and I further agree to be liable for and to pay all costs and expenses incurred in connection with such medical, surgical or dental services rendered to my child pursuant to this authorization.
Parent/Guardian Medical Consent Signature

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Jonathan Daniels Youth Pilgrimage: Youth Registration

Short Answer Questions

Medical Information

Youth Release