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* 1. Please carefully read the "Waiver and Release" available on the "forms" page at SaintChristopherJourneys.com.  Do you agree with the waiver and release? https://saintchristopherjourneys.com/forms.html

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* 2. Please carefully read the "Code of Conduct" available on the "forms" page at SaintChristopherJourneys.com.  Do you agree with the Code of Conduct?https://saintchristopherjourneys.com/forms.html

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* 3. Please carefully read the "Crisis Management Plan" available on the "forms" page at SaintChristopherJourneys.com.  https://saintchristopherjourneys.com/forms.html

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* 4. I understand that all payments are non-refundable and non-transferable.  If not enough participants have been recruited for the journey by the initial deadline and the journey is canceled, I will be reimbursed my payments.

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* 5. First Name:

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* 6. Last Name:

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* 8. Your Cell Phone Number

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* 9. The name of your health insurance company (If you do not have health insurance, just write “none.” Travel insurance may provide some limited health coverage.)

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* 10. Phone number of your health insurance company (If you do not have health insurance, just write "N/A")

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* 11. Your health insurance policy number (If you do not have health insurance, just write "N/A")

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* 12. Your health insurance group number, if applicable:

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* 13. Name of the primary insured person on your health insurance (if you do not have health insurance, just write "N/A")

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* 14. We are collecting medical information from you. It is completely optional for you to share this information. If you have a serious medical condition, we encourage you to wear jewelry that indicates your condition and needs. We compile this information and provide it to your group leader and to your host organization (usually a university or church). While we handle your information carefully, our handling does not meet HIPAA standards for confidentiality. Again, this is optional. Do you have any medical conditions that would be important to know in case of an emergency, and that you would like to share with us?

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* 15. We are collecting medical information from you. It is completely optional for you to share this information. If you have a serious medical condition, we encourage you to wear jewelry that indicates your condition and needs. We compile this information and provide it to your group leader and to your host organization (usually a university or church). While we handle your information carefully, our handling does not meet HIPAA standards for confidentiality. Again, this is optional. If you would like, please share a list of medications you anticipate that you will be taking while on your journey.

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* 16. Do you have any special dietary needs?

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* 17. Do you have any special needs that would be helpful to know in planning your travel?

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* 18. Name of a person not traveling with you who we should contact in case of an emergency:

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* 20. Phone number of the person to contact in case of an emergency:

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* 21. Carpooling is convenient and helpful to our environment. Some participants are choosing to carpool to Hannibal/Quincy. The group will leave from and return to the CSJ mother house. You can choose to have your name, email, and cell number added to a list of those who wish to carpool. This is "at your own risk." We are not vetting drivers nor organizing the carpooling. Do you wish to have your name, email, and cell number added to a list for those wishing to carpool?

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* 22. As part of your signing and consent, please provide today's date

Date

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* 23. Signature: Please type out your full name as a form of electronic signature:

You can mail your $40 payment to 4015 Botanical Ave., St Louis MO 63110 (make check payable to "Saint Christopher Journeys"). If you wish to pay by Zelle bank transfer, send your $40 to Michael Maher with the email address MichaelJMaherJr@yahoo.com.

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