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All-Parish Retreat Medical
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
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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
*
First
Last
Email
Cell Phone
Birth Date
*
MM slash DD slash YYYY
Dietary Resctrictions
Allergies
Medications
Known Medical Conditions
Additional information
Please provide information you would like to share in case of an emergency.