Raphael Registration Form

Raphael Registration Form

Please use this form to register your interest to join the Raphael Pilgrimage to Lourdes. Once you have completed this form we will contact you with information on how to confirm your place with our tour company Tangney Tours.
Thank you for expressing an interest in joining Raphael Pilgrimage to Lourdes. Our group of pilgrims includes those who need some assistance as well as those who want to volunteer, nurses, carers, priests and those who simply want to visit Lourdes.

The form collects some information about you and how you want to be part of Raphael Pilgrimage to Lourdes. The form also asks for some brief information about health, mobility and medications. We do ask that all those who want to travel with Raphel to provide this information. We use it to make sure we all stay safe in our time on Pilgrimage in Lourdes with Raphael.

All personal health and medical information you share is kept confidential. It is reviewed by the Chief Nurse. The information will be used to ensure appropriate support and care is available while in Lourdes. It may be used as appropriate by the nursing team if you become unwell or need medical assistance whilst in Lourdes.

If you have any concerns about supplying this information please do get in touch.
Name*

First NameLast Name
Postcode

Street Address Line 2

CityState / Province

Postcode
Date of birth
Preferred contact phone number*
This can be your home or mobile number
Mobile Number
E-mail
example@example.com
General pilgrimAssisted pilgrimCarer for named pilgrimClergyGeneral helperNurseHealth care assistantDoctor
Reader at MassPlaying music at MassEucharistic MinisterReader at other Pilgrimage eventsLead the RosaryTaking the collection at Mass
There can be lots of walking during our Pilgrimage and for the processions. Sometimes pilgrims will use a wheelchair at times even if they don't need to use one at home. We are able to offer support for this if needed. We would like some information about your mobility.

The following will give us more information about your mobility.

Rows	No	Yes	Details, please give us any further information that you want to share
Is there a limit to how much you can walk?
Do you use a walking aid e.g stick, frame?
Do you use a wheelchair at home?
Will you bring a wheelchair with you?
Do you use a scooter at home?
Will you bring a mobility scooter from home?
Do you think you might need to use a wheelchair at times during the pilgrimage?
Will you want to hire a mobility scooter in Lourdes? This will be an extra cost.
Are you able to get in to bath without assistance?

To help us further understand your mobility, how far can you walk without a rest?
Electric bedHoistCommodeGrab rail beside the toiletRaised toilet seatWalk in showerShower seatOther
RIGHTLEFTEither side

Please enter below any medication you take including prescribed, over the counter, herbal, other. It is advised that you bring a supply of medication for 2 weeks with you.
Do you have any allergies to food, medication or the environment? Please enter any details below.
Have you had any operations in the last 12 months? If so please enter the details below.

It is helpful for us to know your home situation and any care needs that you have at home. This information will help us ensure you have a hotel room in Lourdes that best suites your requirements.
I live independentlyI live on my own but have others or carers to help me at times during the dayI am fully dependent on others for helpOther

If you have carers, dependent on others or need additional support for your day to day living, please briefly describe the help you receive below.
Please tell us if someone who can meet your day to day needs will be travelling with you to Lourdes? Please tell us their name and their relationship to you.

Rows	Yes
I need help washing and/or dressing
I need help with feeding /drinking
I have continence issues
I need help during the night

Do you have any dietary requirements e.g vegetarian, vegan, gluten free, low-sugar (diabetic), low salt, low fat.
Are there any specific foods that you CANNOT eat e.g due to allergies, intolerance?
If you would like to tell us anything else that you think is relevant please use the box below. If this is your first time applying to be part of Raphael Pilgrimage please let us know how you found out about us.
Thank you for taking the time to complete this form. Please now click submit. This form acts as the start of your booking. The information will be sent to the Chief Nurse who may contact you if they need any further information. This allows us to make sure we are able to support you during your time with Raphael. We will always discuss with you if we are concerned that we can't meet your needs.

Once the initial checks and registration process is complete we will send you a further email which will include a link to book your place with Tangney Tours.
Should be Empty:

Rows	NO	YES	Any relevant details of the health condition particularly if it impacts on you on a day to day basis
Asthma/COPD
Cancer
Diabetes
Epilepsy
Heart disease
High blood pressure
Kidney disease
Stroke

Raphael Registration Form

Medical information