March for Life Registration Form

March for Life, 2025 Registration Form

***One Form per Participant ***

SECTION A - Registration Information

Participant's Name*

Date of Birth*

Date

Street Address*

Parish*

City/State/ZIP*

Phone number*

Please select one:*

What is the student's grade?*

Parent's names*

Cell Phone (required if you are a chaperone)*

Name for name badge*

Participant's Email*

example@example.com

SECTION B - Medical Treatment Authorization

To Whom It May Concern: I hearby authorize treatment for my child/myself by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me/my family.

Reason for which release is intended: March for Life, 2025

Participants Name*

Relationship to participant?*

SonDaughterSelfOther

Emergency Contact Name*

Emergency Contact Phone #*

Family Physician*

Physician Phone #*

List allergies including food allergies medication contacts or other pertinent comments. Prescription medication must be provided in original containers and placed in a resealable bag with youths name clearly printed*

Health Insurance Data:

Do you have Health Insurance?*

Company*

Policy*

Group*

I further authorize the person who presents the minor and/or adult participant, to sign the Acknowledgment of Receipt of Notice Privacy Rights, that may be presented by the physician or health care facility. This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.

Adult Participant's or Parent/Guardian Signature*

Adult Participant or Parent/Guardian*

Date*

Date

SECTION C - Adult Code of Conduct and Safe Environment Policy I have read and understand the Code of Conduct from the Archdiocese of Anchorage-Juneau have completed the Safe Environment Training, and agree to follow them for the March for Life.

Adult Participant's Signature*

Adult Participant*

Date*

Date

SECTION D - Youth Behavior Guidelines I have read and understand the Code of Conduct from the Archdiocese of Anchorage-Juneau and agree to follow them for the March for Life. As parent or legal guardian, I remain fully responsible for the actions and conduct of my child. If it is necessary for my child to return home before the group returns, I understand it will be at my expense.

Youth Participant*

Parent's Signature*

SECTION E - Parental Statement of Consent (must be completed for those under the age of 18) I hereby consent to participation by my child, held January 21-26, 2025, in Washington, D.C. I understand that my child will be under the supervision of the designated Archdiocesan and parish employee/volunteers on the stated dates. I further consent to the conditions regarding participation in this event, including the methods of transportation.

In consideration of my child being allowed to participate in the March for Life, I agree to indemnify and hold harmless and defend the Catholic Archdiocese of Anchorage-Juneau, any and all affiliated parishes, organizations, their employees, agents, and representatives, including volunteers and other drivers, from any and all claims, including negligence, arising from or relating to my child's participation in this event. This indemnification and hold harmless and defense agreement does not apply to claims for intentional misconduct.

Parent's Signature*

Parent's Name*

Date*

Date

SECTION F - Media Release

I hereby give permission for the personnel of the Catholic Archdiocese of Anchorage-Juneau to photograph, videotape and/or record my child/children (or allow area news reporters to do the same for the purposes of (please check the items you will allow):*

In-School/Parish Purposes use onlyPublic information for promotion of Archdiocesan Schools, or Parish programs (brochures, newspapers, radio, or television) Parish websiteCatholic Archdiocese of Anchorage-Juneau websiteI do not give permission for my student to be photographed, videotaped or voice-taped

Student/Participant Name*

Parent/Guardian Signature*

Parent/Guardian Printed Name*

Date*

Date