Permission Slip

Please text or call Colleen Miner 518-524-0774 to check if there is still room available, before you register. Thank you.

Youth Buses for Life
March for Life 2019
Washington, DC Pilgrimage

If you are a chaperone, please click here to fill out the correct form.

The Youth Buses for Life will depart on Thursday, January 23, 2020 and return on Sunday, January 26, 2020. The Youth Buses for Life pilgrimage is open to high school Students. The Northern Bus will depart at 6:00am at Trinity Catholic School’s parking lot in Massena with a pickup in the parking lot next to St. Mary’s Church in Canton at 6:30am and at 7:15am at St. James Church in Gouverneur. The Western bus will depart from Immaculate Heart Central Jr/Sr High School parking lot in Watertown at 8:00am. The hotel we will be staying at is the Hilton Garden Inn in Arlington, VA (703-418-8181). The cost of the pilgrimage is $200.00, which includes transportation, hotel accommodations, three breakfasts, two lunches, two dinners, t-shirt and sling bag.

All registrations must include a non-refundable $200.00 pilgrimage fee. Upon completion of the form, you will be forwarded to PayPal. To pay by check, please make the check payable to Youth Buses for Life, PO Box 106, Canajoharie, NY 13317 and include the Student’s name. The registration form cannot be saved and must be completed in its entirety.

Today's Date:

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Submitted by: (*)

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Student's Information

Student's Last Name: (*)

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Student's First Name: (*)

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Date of Birth: (*)

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Gender:(*)

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Grade:(*)

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Street Address: (*)

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City:(*)

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State:(*)

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Zip Code:(*)

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Home Phone:

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Cell Phone:

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NOTE: If you do not have a cell phone, please try and borrow one.

Email Address:

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Your Parish:(*)

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Parish City(*)

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Shirt Size: (Unisex Short Sleeved Shirts)(*)

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Parent/Legal Guardian Information

Last Name:(*)

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First Name:(*)

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Is your address different than the above Student’s(*)

YesNo Invalid Input

Street:(*)

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City:(*)

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State:(*)

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Zip Code:(*)

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Home Phone:

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Cell Phone:(*)

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Email:(*)

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2nd Parent/Legal Guardian Information

Last Name:

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First Name:

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Is your address different than the above Student’s

YesNo Invalid Input

Street:

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We read the Detailed Itinerary of the pilgrimage.

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We read a Detailed List of Items the Student should/should not bring.

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Section A – Travel Arrangements

Which bus are you registering for?(*)

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Northern (departs from Sacred Heart in Massena with pick ups at St. Mary's in Canton and St. James in Gouverneur)
Western (Departs IHC high school)

Who will be picking the Student up when the Youth Buses for Life returns on Sunday, January 26, 2020: (*)

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eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I hereby give permission for my child to travel on the Youth Buses for Life to the March for Life in Washington, DC from Thursday, January 23, 2020 until Sunday, January 26, 2020. The Student may be picked-up on Sunday, January 26, 2020 at the bus pick up point at approximately 8:00pm in Watertown, 9:00pm in Gouverneur, 9:30pm in Canton and 10:00pm in Massena. My child will miss school on Thursday, January 23, 2020 and Friday, January 24, 2020.

Section B - Student's Health Information

Is the Student covered by health insurance?

Is the Student covered by health insurance?(*)

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Carrier Name: (*)

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Plan Name:(*)

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Subscriber Id: (*)

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A photocopy of the front and back of your health insurance card must be provided. If you are unable to upload your health insurance card, please mail a copy to: Diocesan Faith Formation, Attn: Andi Page, 4917 South Catherine Street, Plattsburgh, NY 12901 or email to apage@rcdony.org

Insurance Card Upload

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Healthcare Provider Information

Healthcare Provider: (*)

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Healthcare Provider’s Address: (*)

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Healthcare Provider’s Phone #: (*)

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Does the Student have a medical or physical condition or allergies which could interfere with their safety:(*)

YesNo Invalid Input

Please explain in detail: (*)

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Does the Student have any physical restrictions(*)

YesNo Invalid Input

Please explain in detail: (*)

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Do you give permission for a Youth Bus for Life staff member to administer Ibuprofen or Tylenol to the Student?(*)

YesNo Invalid Input

Please explain in detail: (*)

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Does the Student require administration of any prescription medication during the pilgrimage:(*)

YesNo Invalid Input

Please explain in detail: (*)

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Self-Directed Medication

Is the Minor capable and competent to administer their prescribed medication to his/her self and to self-carry their prescribed medication?

(*)

YesNo Invalid Input

eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I certify the above-mentioned Student is capable and competent to administer their prescribed medication and to self-carry their prescribed medication.

eSignature of Student: (*)

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By eSigning my name above, I certify that I have been instructed in and understand the purpose, time of day, dosage, frequency of my prescribed medication and consider myself capable and competent to administer and self-carry my prescribed medication.

eSignature of Parent/Legal Guardian (*)

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By eSigning my name above, I hereby affirm and certify that the information provided in Section B – Student’s Health Information is complete and accurate. My child has my permission to engage in the Youth Buses for Life activities except as noted.

Section C - Emergency Contact Information

If a Parent/Legal Guardian cannot be reached in case of an emergency, please contact:

Emergency Contact Name: (*)

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Relationship to Student: (*)

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Street Address: (*)

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City:(*)

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State:(*)

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Zip:(*)

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Home Phone:

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Cell Phone:(*)

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Work Phone: (*)

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Emergency Contact Name: (*)

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Relationship to Student: (*)

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Street Address: (*)

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City:(*)

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Home Phone:

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Cell Phone:(*)

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eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I hereby authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above-named Student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event, it becomes necessary for the staff of the Diocese of Ogdensburg Youth Buses for Life in charge to obtain emergency care for my child, neither he/she nor the Diocesan staff assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstance.

Section D – General Rules

Boundaries - All Students must remain within the given boundaries and areas of the pilgrimage.

No Alcohol, Illegal Drugs, Tobacco or Vaping – These substances are prohibited during the pilgrimage.

Behavior and Dress Code – All Students are expected to behave and dress in an appropriate manner throughout the pilgrimage. The following dress code must be followed throughout the pilgrimage: no clothing with advertisements for alcohol, drugs or tobacco. No inappropriate slogans or designs. Shirts must cover the midriff. Skirts, dresses or shorts must be no more than five inches above the knee.

Respect the Staff – All staff will be given the Student’s respect, courtesy and cooperation during the pilgrimage.

Illness or Injury – Any illness or injury during the pilgrimage must be reported to a staff member immediately.

Any serious infraction of the rules will result in a call to the Student’s Parent/Legal Guardian and possible dismissal from the pilgrimage. The Parent/Legal Guardian will be responsible to pick the Student up from the pilgrimage.

eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I certify that I have read and understand Section D – General Rules.

eSignature of Student: (*)

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By eSigning my name above, I certify that I have read and understand Section D – General Rules.

Waiver and Release of Liability: Indemnification and Hold Harmless Agreement

In order for my child to participate in the Roman Catholic Diocese of Ogdensburg’s Youth Buses for Life pilgrimage, I agree as follows:
1. Acknowledgement of Risk. I acknowledge and fully understand that there are inherent risks of serious injury or death associated with hiking, backpacking, canoeing, swimming and other activities associated with the Youth Buses for Life. These inherent risks include but are not limited to: encountering natural dangers such as falling rocks or objects, irregular or uneven ground, unseen or unmarked objects, drowning or serious injury in and around water could occur due to water movement, subsurface conditions, cold water temperature, water impurities and the like. Inherent risks also include acts or omissions of other Students or Students, the condition of equipment or property, even if properly maintained; weather conditions (such as lightning strikes, sunburn, rain or hail storms, tornadoes and the like), contact with plants, animals or insects, the risk of My Child or other Students engaging in unauthorized activities, My Child’s physical condition(s) or My Child’s own acts and omissions, conditions or roads, trails, waterways or terrain, the administration and availability of first aid and emergency treatment and consumption of food or drink by My Child. My Child further acknowledges that the inherent risks associated with activities at the Youth Buses for Life, including hiking, backpacking, swimming and canoeing cannot be comprehensively described as part of this document.
2. Assumption of Risks. I hereby release, waive and discharge the Roman Catholic Diocese of Ogdensburg’s Youth Buses for Life, its employees and agents from liability claims and demands of negligence on the part of the Youth Buses for Life, its employees and agents arising in connection with the participation in the Youth Buses for Life pilgrimage, including, but not limited to, those risks described in paragraph one (1) above; providing, however, that this waiver and release does not include injury, damage, or loss as a result of the gross negligence of the Youth Buses for Life, its employees and agents.
3. Indemnification and hold harmless. I further agree to indemnify and hold harmless the Youth Buses for Life, its employees and agents, against all losses, damages, monetary awards and expenses, including all costs and attorney fees incurred in connection with any and all claims of negligence on the part of the Youth Buses for Life, its employees and agents, brought by My Child, his/her heirs, successors, assigned and legal representatives for any injury, death, illness, disease or damage to property, arising from or connected with participation in any activity of the Youth Buses for Life. The indemnification and hold harmless agreement does not include losses, damages, monetary awards and expenses as a result of the intentional or reckless acts of the Youth Buses for Life, its employees and agents.
4. Miscellaneous. The parties agree that the provisions of this “Waiver and Release of Liability; Indemnification and Hold Harmless Agreement” (“Agreement”) shall be deemed severable and that the invalidity or unenforceability of any one or more of the provisions or clauses hereof shall not affect the validity or enforceability of the other provisions or clauses hereof except as specifically set forth herein. The terms of this Agreement constitute the entire agreement and understanding between the parties. This Agreement is made pursuant to and shall be construed under the laws of the State of New York.
5. Opportunity to Negotiate. You are encouraged to carefully review the contents of this Agreement and take the necessary time to review it. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. You may wish to consult an attorney. If you wish to negotiate any of the terms of this Agreement for modifications, deletions or additions, please contact the Roman Catholic Diocese of Ogdensburg Respect Life Director (“Director”) at (315) 393-2920 ext. 1415 prior to signing and executing this Agreement. If you do not contact the Director prior to signing and executing this Agreement, the Youth Buses for Life understands that you are accepting the terms and conditions as set forth above, and that you do not wish to pursue any further negotiations regarding the terms and conditions of this Agreement.

eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I certify that I have read the Waiver and Release of Liability; Indemnification and Hold Harmless Agreement and I understand that My Child/Ward is giving up substantial rights and assuming substantial responsibilities, and that I sign it voluntarily.

eSignature of Parent/Legal Guardian: (*)

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By eSigning my name above, I hereby affirm and certify that the information provided in the Youth Buses for Life registration form is complete and accurate to the best of my knowledge.

Once your registration form is submitted and payment processed, you will be forwarded to the Diocesan Photo/Video release form. http://www.rcdony.org/photo (you can click on this link and it will open in a new tab) Please fill out a release form for each participant.

Thank You.

Verification(*)

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