Avila University Journey to Western Kansas March 2025 Question Title * 1. In order for your registration to be complete, you need to send a closeup digital photo of yourself (that really looks like you) to MMaher@SaintChristopherJourneys.com. This is only used in case of an emergency. Please do not worry about having a "great picture." Just a recent, accurate photo is fine (a selphie snapshot from a phone for example). Yes, I have emailed a photo of myself to MMaher@SaintChristopherJourneys.com Question Title * 2. 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 Yes, I have read the Waiver and Release, and I agree to it. Question Title * 3. 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 Yes, I have read the Code of Conduct, and I agree to it. Question Title * 4. Please carefully read the "Crisis Management Plan" available on the "forms" page at SaintChristopherJourneys.com. https://saintchristopherjourneys.com/forms.html Yes, I have read the Crisis Management Plan. Question Title * 5. 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. Yes, I understand conditions, and I agree to pay fees according to the schedule in the journey brochure. Question Title * 6. First Name: Question Title * 7. Last Name: Question Title * 8. Date of Birth (This is used to purchase your travel insurance.) (Month/Day/Year MM/DD/YYYY) Date Question Title * 9. Email address you use most often: Question Title * 10. Your Cell Phone Number Question Title * 11. Your mailing address, including zip code: Question Title * 12. Your Gender (this is used for housing assignments) Male Female Other (please specify) Question Title * 13. 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.) Question Title * 14. Phone number of your health insurance company (If you do not have health insurance, just write "N/A") Question Title * 15. Your health insurance policy number (If you do not have health insurance, just write "N/A") Question Title * 16. Your health insurance group number, if applicable: Question Title * 17. Name of the primary insured person on your health insurance (if you do not have health insurance, just write "N/A") Question Title * 18. 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? Question Title * 19. 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. Question Title * 20. Do you have any special dietary needs? Question Title * 21. Do you have any special needs that would be helpful to know in planning your travel? Question Title * 22. Name of a person not traveling with you who we should contact in case of an emergency: Question Title * 23. Email address of the person to contact in case of an emergency: Question Title * 24. Phone number of the person to contact in case of an emergency: Question Title * 25. If you would like to provide a second emergency contact (of a person not traveling with you), please provide their name, email address, and phone number. Question Title * 26. As part of your signing and consent, please provide today's date Month/Day/Year (MM/DD/YYYY) Date Question Title * 27. Signature: Please type out your full name as a form of electronic signature: Done