Walking the Way: Our Black Catholic Foremothers in Faith

Walking the Way: Our Black Catholic Foremothers in Faith

FutureChurch Racial Justice Pilgrimage Registration Form.
Use this form to register for FutureChurch's Pilgrimage, "Walking the Way: Our Black Catholic Foremothers in Faith."

Alternately, you may download, print, and return by US Mail a paper form by visiting https://futurechurch.org/pilgrimage.

To complete this form, you will need:
- Your name as it appears on your driver's license or passport
- Emergency Contact Name and Phone number
- Physician Name and Phone Number
- Your medical insurance information: Company name, phone number, policy holder name, policy #
- To make a first payment of $500.00. Payment options include paying online by credit card or paying by check through the mail. Payment details will be provided upon submission of the registration form.

Registration Information
Participant Name as it appears on driver's license or passport:*

PrefixFirst Name (Required)Middle Name (Required)Last Name (Required)Suffix
Participant Date of Birth*

MonthDayYear
Date
Participant Gender Identification*

MaleFemaleNon BinaryOther
Participant Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*
Please enter a valid phone number.
Cell/Secondary Phone Number (if you only use a cell phone, please put the number in both this field and the field above)*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
If participant is under 18 years of age, print parent or guardian name

First NameLast Name
Signature: by signing below you agree to the terms and conditions (linked above) and to hold FutureChurch and its representatives harmless (as stated above).
Participant or Parent/Guardian Signature* Date*

Accommodations
Type of Room Requested*

Double ($2,200)Single ($2,800)
Please Note Our Payment Schedule

1st Payment: $500
Due at registration by November 1, 2023

2nd Payment: $1,000
Due by December 12, 2023

Final Payment: $700 (double) / $1,300 (single)
Due by February 20, 2024

Pricing does NOT include airfare. Participants are responsible for making their own arrangements to arrive in Atlanta, GA by 11:30am ET on May 2, 2024 and to return home from New Orleans, LA after 2pm ET on May 7, 2024.

You will receive payment option details upon form submission.

Permission for Medical Treatment

Every tour member (students and adults) must complete and return a separate form. The tour leader will have this form in their possession while on tour for emergency purposes.
Participant's Full Legal Name*
Physician's Name*
Physician's Phone Number*
Please enter a valid phone number.
List fully any medical conditions and/or physical limitations participant may have *
(i.e. wheelchair accessible motorcoach, food allergies, etc. Please note that this trip involves considerable walking)
List any allergies the participant has. If none, please indicate so:*
The accident insurance included as part of the tour package covers medical expenses and transportation expenses only for an ambulance to the hospital. IF MEDICAL TREATMENT SHOULD BE REQUIRED FOR A NON-TOUR RELATED INCIDENT,
I authorize the use of our family medical insurance policy*

Accept
Insurance Company Name*
Insurance Company Phone Number*
Please enter a valid phone number.
Policy Holder Name*
Policy Number*
It is understood and agreed that the tour sponsors and chaperones will exercise reasonable care with respect to the health and physical well-being of each participant. This permission also authorizes chaperones to observe students who must take any such medications as Tylenol, Anti-diarrhea medication or medications designed for relief of minor problems as they become necessary. I have read the foregoing and agree to the stipulations there in: I hereby authorize any medical treatment necessary & the transfer of the student or participant to any reasonably accessible hospital, pursuant to the foregoing conditions:*

Accept
Should a medical emergency prevent the tour participant (and a chaperone if the participant is under 18 years old) from traveling back with the group, I hereby give my permission for the tour participant to travel with that designated chaperone (without the group) once the participant has been released from the place where medical attention was given. For minors; the mode of return travel for a student will be determined by the both the Chaperone in charge and the Parent/Guardian of the participant. I also understand that I will be responsible for the travel expense for both the tour participant and the Chaperone (if the participant is under 18 years old) to return home. If you purchase Optional Travel Protection Insurance, part of this expense may be covered. If the Optional Travel Protection Insurance was not offered to your group, please contact Hemisphere to see what insurance coverage would be available for the type of tour you are taking.*

Accept
SWIMMING AND OTHER PHYSICAL ACTIVITIES: AS A PARENT/GUARDIAN OR TOUR PARTICIPANT, I ACKNOWLEDGE THAT IN CONNECTION WITH SWIMMING AND OTHER PHYSICAL ACTIVITY I HAVE FULLY ADVISED THE TOUR LEADER OF ALL LIMITATIONS THAT MY CHILD OR MYSELF MAY HAVE IN PARTICIPATING IN THE TOUR ACTIVITIES. I UNDERSTAND THAT SWIMMING, WITH OR WITHOUT A LIFEGUARD PRESENT, ARE AT ONE’S OWN RISK. I HEREBY RELEASE HEMISPHERE EDUCATIONAL TRAVEL, THE GROUP, THE TOUR LEADERS AND CHAPERONES FROM ANY RESPONSIBILITY FOR PERSONAL INJURY OR OTHER LOSS WHICH MIGHT OCCUR WHILE ENGAGING IN SWIMMING OR OTHER TOUR ACTIVITY UNLESS SUCH INJURY OR LOSS IS CAUSED BY THE GROSS NEGLIGENCE OF HEMISPHERE EDUCATIONAL TRAVEL OR THE CHAPERONES. PLEASE CHECK WITH YOUR TOUR LEADER TO SEE IF SWIMMING IS PART OF YOUR GROUP’S ITINERARY.I HEREBY AGREE TO ALL OF THE TERMS ASSOCIATED WITH THIS RELEASE FORM.*

Accept
Signature
Signature* Date*
Should be Empty:

Walking the Way: Our Black Catholic Foremothers in Faith

Registration Information

Accommodations

Please Note Our Payment Schedule

Permission for Medical Treatment