Province III Youth Pilgrimage

Trail to Truth: Racial Reconciliation

From Washington D.C. to Philadelphia

The Diocese of Central PA is inviting Senior High ( 9th through 12th grade) Youth to participate in the Province III Youth Pilgrimage, "Trail To Truth". This pilgrimage offers you the opportunity to be part of a a Social Justice Ministry through deepening an understanding of Eliminating Racism.
For more detailed information about the Province III Youth Pilgrimage, visit the Province III website at: https://www.province3.org/blog/trail-to-truth-racial-reconcilliation-youth-pilgrimage/

Since we are only permitted six senior high youth, we invite you to respond to the following questions. Answer as best you are able, we want to know what you are thinking.

We also need the following information from you.

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* 1. Pilgrim Personal Information:

First Name:

Last Name:

Phone#:

Address:

Email:

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* 2. Date of Birth: mm/dd/yyyy

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* 3. Age as of today:

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* 4. Have you ever witnessed a racist act? If you have what did you do? and how did you feel?

Your Witness to a racist act:

What did you do?

How Did you feel?

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* 5. Describe the meaning of racism.

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* 6. The Episcopal Church is working to correct some of the disparities caused by race; Why should the church be involved with race and racism?

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* 7. In 50 years, what, if anything, will be the race issues of the day? What do you think the state of racism will be in 50 years?

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* 8. If 18 or older, Clearances that are up-to-date? (within the last 5 yrs) Check all that apply.

Child Abuse

Criminal Record Check

FBI Fingerprint

Affidavit of Residency

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* 9. Doctor’s Information:

Doctor's Name:

Doctor's Phone#:

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* 10. Health Insurance Information:

Company Name:

Group #:

Plan #:

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* 11. Parents or Guardians should complete the following Medical Information and Release:
Any Health problems the staff should know about?

Yes

If Yes (please specify)

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* 12. Do you have any Allergies?

Yes

If Yes (please specify)

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* 13. Do have any dietary restrictions or allergies to any foods?

Yes

If Yes (please specify)

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* 14. Will you need any prescribed medications to be taken during the event?

Yes

If Yes, Provide name of medicine, dosage, and frequency if not listed on medication.
Please provide a sufficient supply of medicine for the period of this event.

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* 15. Father's Contact Information:

Father Name:

Father Cell Phone#:

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* 16. Mother’s Contact Information:

Mothers Name:

Mothers Cell Phone#:

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* 17. Emergency contact during event: (if other than parents above)

Emergency Contact Name:

Cell Phone#:

2nd Phone #, if applicable:

Relationship to Pilgrim:

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* 18. In case of a medical emergency, I permit the diocesan staff and/or adult supervisors to obtain or authorize emergency medical/dental treatment for my child. I further authorize the medical personnel selected by the diocesan staff and/or adult supervisors to administer such emergency treatment, including injections, anesthesia, or surgery as they deem necessary. I understand I will be notified of this emergency as soon as possible.

Parent Agrees

Parent Disagrees

Special Instructions: (please specify)

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* 19. Parents Signature (by parent entering their name, the parent agrees the above information is true and correct to the best of their knowledge)

Signature:

Date:

Province III Youth Pilgrimage

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* 1. Pilgrim Personal Information:

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* 2. Date of Birth: mm/dd/yyyy

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* 3. Age as of today:

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* 4. Have you ever witnessed a racist act? If you have what did you do? and how did you feel?

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* 5. Describe the meaning of racism.

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* 6. The Episcopal Church is working to correct some of the disparities caused by race; Why should the church be involved with race and racism?

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* 7. In 50 years, what, if anything, will be the race issues of the day? What do you think the state of racism will be in 50 years?

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* 8. If 18 or older, Clearances that are up-to-date? (within the last 5 yrs) Check all that apply.

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* 9. Doctor’s Information:

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* 10. Health Insurance Information:

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* 11. Parents or Guardians should complete the following Medical Information and Release:Any Health problems the staff should know about?

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* 12. Do you have any Allergies?

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* 13. Do have any dietary restrictions or allergies to any foods?

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* 14. Will you need any prescribed medications to be taken during the event?

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* 15. Father's Contact Information:

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* 16. Mother’s Contact Information:

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* 17. Emergency contact during event: (if other than parents above)

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* 19. Parents Signature (by parent entering their name, the parent agrees the above information is true and correct to the best of their knowledge)

* 11. Parents or Guardians should complete the following Medical Information and Release:
Any Health problems the staff should know about?