JrH activities registration

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First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Address Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Email REQUIRED Please fill out this field. Please enter an email address.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Date of Birth (xx/xx/xxxx) REQUIRED Please fill out this field. Please enter a date.
T-Shirt Size - (estimated size in June 2023) REQUIRED Please fill out this field.
Have you been to Brave or Expedition before?
Consent and Liability Waiver
I agree on behalf of myself, my heirs, successors and assigns, to hold harmless, release and defend the Archdiocese of Galveston-Houston, Office of Adolescent Catechesis and Evangelization, the parish/school/organization its employees, officers, volunteers, agents, or representatives from any claims, damages or liabilities, cost or expense arising from or in connection with my attendance at the Brave the Wilderness/Expedition Retreat. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary. I fully understand the foregoing statements and sign this Adult Medical Consent and Liability Waiver knowingly, freely, and willingly.

In checking the box below, I certify that all information contained herein is true and accurate to the best of my knowledge.
I Agree Please select this field.
Video/Photography Consent

I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event
Video/Photography Consent REQUIRED I grant permission I do not grant permission Please fill out this field.
Medical Matters
I hereby warrant to the best of my knowledge, I am in good health, and I assume all responsibility for my health. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:

Emergency Medical Treatment
In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor and I understand that all financial obligations are my responsibility.
In the event of an emergency and you are unable to reach me, contact:
Name and Relationship: REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Family Doctor: REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Medications
I will bring all such medications, well labeled, that are necessary. Names of medications and concise diretions for seeing that I take such medications, including dosage and frequency are as follows:
Medications, Dosage, and Instructions:
Please Select One of the Following:
I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be administered to me, if deemed advisable. I understand that Aspirin will not be given to me. I grant permission
I hereby do not grant permission for medication of any type, whether prescription or nonprescription may be administered to me unless the situation is life-threatening and emergency treatment is required I do not grant permission
Medical Conditions Information (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence)

I have:
Has had an episode of the following or has been diagnosed: REQUIRED Please fill out this field.
Allergic Reactions to the Following (foods, dyes, latex, etc.) Please enter valid data.
Dietary Restrictions: Please enter valid data.
Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
If yes to the above, is still under a doctor's care? Yes No
Has a medically prescribed diet? Yes No
The following physical limitations: Please enter valid data.
Immunizations current and up to date? REQUIRED yes no Please fill out this field.
Date of last Tetanus/Diphtheria immunization: Please enter valid data.
You should also be aware of these special medical conditions (e.g. depression, anxiety, etc.):
Insurance Information
Do you have medical insurance at this time? REQUIRED Yes No Please fill out this field.
Insurance Carrier REQUIRED Please fill out this field. Please enter valid data.
Name of Insured REQUIRED Please fill out this field. Please enter valid data.
ID/Policy Number REQUIRED Please fill out this field. Please enter valid data.
Group Name/Number REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

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JrH activities registration

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston

Office Hours

JrH activities registration

St. Bernadette Catholic Church Archdiocese of Galveston-Houston

Office Hours

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston