All-Parish Retreat Medical Form

Family Name*
Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Insured Name*
Name as it appears on your insurance card.
First Last
BIrth Date of Insured*
MM slash DD slash YYYY
Health Insurance Carrier*
Carrier Group Number Policy Number
Insurance Carrier Phone*
Individual Info
Please add info for each person attending the retreat.
Name Actions
There are no Individuals.
Maximum number of individuals reached.
Emergency Contact Name*
Please share contact info for someone who is NOT traveling with you.
First Last
Phone*
Email
MEDIA RELEASE: Parents Only
As a parent or legal guardian of the child/children listed above, I grant permission for my child/children to participate in Saint Barnabas All-Parish Retreat. I give permission for photography of my child to be used on the Saint Barnabas website, Facebook page, newsletter, and other printed/digital publications for no purpose except that of promoting the life and community of Saint Barnabas Episcopal Church.
I agree
MEDICAL RELEASE*
I direct the leadership of Saint Barnabas on the Desert to authorize such medical care for the
person(s) listed here as is deemed necessary in an emergency.
I agree
ELECTRONIC SIGNATURE*
I certify that by typing my name below in the Electronic Signature Field and submitting this form, I intend to sign this document and be bound to the same extent as if I had provided a physical signature.

Name	Actions

There are no Individuals.