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Wounded or Disabled Military Personnel and Companion-Caregiver Application 2014 Archdiocese for the Military Service (AMS) and Knights of Columbus (KofC)

Warriors to Lourdes Pilgrimage, May 13-19, 2014

INSTRUCTIONS & CHECKLIST Please use this as your checklist to ensure that a fully COMPLETE application is submitted. The following documents are REQUIRED to submit a COMPLETE application packet for review and consideration. Incomplete applications will be set aside and only considered when complete. Originals only as noted — no fax or email submissions will be accepted. Please ensure the following five (5) ORIGINAL documents are attached to be considered a COMPLEFTE application.

r APPLICATION PACKET CHECKLIST

r WOUNDED OR DISABLED MILITARY PERSONNEL APPLICATION (PAGES 2-5)

r PROTECTED HEALTH INFORMATION RELEASE (PAGE 6)

r COMPANION-CAREGIVER APPLICATION (PAGES 7-9)

r SIGNED PHYSICIAN EVALUATION OF MEDICAL CONDITION FORM

ORIGINAL FORM MUST BE COMPLETED AND SIGNED BY TREATING PHYSICIAN, THEN ATTACHED TO THE APPLICATION

r SIGNED LETTER OF ENDORSEMENT FROM PRIEST/CHAPLAIN SPONSOR

r COMPLETED AND SIGNED PILGRIMAGE RELEASE OF ALL LIABILITY AGREEMENT

All AMS-KofC Lourdes 2014 Pilgrimage applicants must submit the required documents noted above. The Wounded or Disabled Military Personnel and Companion Application Forms and Protected Health Information Release must be completed in full (either typed or printed), signed and submitted via U.S. Mail along with the completed Evaluation of Medication Condition Form (which must be completed and signed by the applicant’s treating physician). Applicants accepted for the pilgrimage will be asked to acknowledge their acceptance in writing. An additional publicity release and other items will be included with this acknowledgement. All original, completed and signed applications and supporting materials must be received (NO emails or faxes accepted) by Friday, Jan. 10, 2014, to:

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

If you have any questions concerning this application, please call (203) 752-4633 or email Lourdes@KofC.org. For general information about the 2014 Warriors to Lourdes Pilgrimage, please visit our website at: WarriorstoLourdes.com

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Wounded or Disabled Military Personnel Application PERSONAL INFORMATION

Legal Last Name: __________________________________ Legal First Name: ______________________________ Nickname: _____________________________ Gender: Male q Female q DOB: ______________________ Home Address: _________________________________ City: _______________ State: _____ ZIP: __________ Preferred Phone Number: ___________________________ Email Address: ________________________________ Marital Status: _______________________ Name of Spouse (if married): __________________________________ Companion Information – For wounded or disabled military personnel who currently require a designated companion-caregiver (to help the pilgrim complete their Activities of Daily Living), you are encouraged to invite your designated companion-caregiver (spouse, parent, sibling, best friend, etc.) to serve in this role during the Pilgrimage. Designated companions-caregivers are required to complete the Companion-Caregiver Application Form. I have asked the person below to serve as my companion-caregiver on the 2014 Pilgrimage:

Name: ________________________________________ Relationship: _______________________________

Telephone: (home) _____________________________ (work) __________________________________

Telephone: (mobile) _______________________________ Email: __________________________________ Emergency Contact Information (Your emergency contact should NOT be traveling on the pilgrimage. Suggest a family member or other individual in the United States to be contacted in case of an emergency.)

Name: ________________________________________ Relationship: _______________________________ Home Address: __________________________________ City: ________________ State: _____ ZIP: ________

Telephone: (home) _____________________________ _ (work) _________________________________

Telephone: (mobile) _______________________________ Email: __________________________________ Sponsor/Endorser: Every wounded or disabled military applicant must be sponsored (endorsed) by a military, Veterans Affairs or parish priest/chaplain.

Who is your sponsor/endorser? _____________________________________________________________

Your relationship to the sponsor/endorser: ____________________________________________________

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AIR TRAVEL INFORMATION Passport Information: Passports must be valid through Nov. 20, 2014 (six months after pilgrimage) Name:

(full legal name as it appears in your passport, including first, middle & last name)

Passport Number: _________________________ _______ Nationality:

Expiration Date: _________________________________ Date of Birth: _______________________________ Alien Registration Number (if applicable):

Do you have any difficulties with long airplane rides? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q If yes, please explain: Seat Request (entire flight is coach): q Window q Midd le q Ais le Mea l Requ i rement: S tandard q Spec ia l D ie t q (p lease spec i fy) : (Please note: All attempts will be made to accommodate these requests, but they cannot be guaranteed.) Will you require a wheelchair at the airport (USA or France)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q Do you require oxygen during the flight? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q LODGING AND MEAL INFORMATION

Do you require a handicap accessible hotel room? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q

Do you have any food and/or drug allergies?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q ___________________________________________ If yes, please explain: ________________________________________________________ ______________________________________________________________________________________

Are you on a special diet?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q If yes, please explain: ___________________________________________________________ ______________________________________________________________________________________ Do you require the use of a Hoyer Lift? .................................................................... Y e s q N o q Do you need any bathroom or toilet equipment? ..................................................... Y e s q N o q Do you require a special commode? ..................................................................... Y e s q N o q Do you need bars to get in and out of a bathtub? ................................................... Y e s q N o q Do you need a chair to sit on while you shower? ....................................................... Y e s q N o q

Please note any special requirements or requests you have related to hotel or meals not noted above: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

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GENERAL ASSISTANCE INFORMATION Do you require assistance with:

Taking medications?................................................................................ Y e sq N o q Stepping into a high bathtub?.....................................................................Y e s q N o q Standing/sitting? ..................................................................................... Y e s q N o q Performing daily activities (bathing, dressing, eating, etc.)? ...........................Y e s q N o q

Do you have an aide/helper at home to assist you?..................................................Y e s q N o q If yes, does the aide give you your medicine?..............................................Y e s q N o q Do you use any urinary devices, such as catheters or pads?........................................ Y e s q N o q Do you require any ileostomy or colostomy appliances?............................................. Y e s q N o q Do you have any significant impairment of sight?........................................................ Y e s q N o q Do you wear a hearing aid?....................................................................................Y e s q N o q Do you wear an artificial limb or other prosthetic device?................ ..........................Y e s q N o q If you answered ‘yes’ to any of these questions, please explain below:

Do you have any difficulty walking? ........................................................................ Yes q No q If yes, under what conditions?

How far can you walk unassisted?

Do you have osteoporosis, bone weakness, or an increased risk of bone fracture? ...........Yes q No q Can you climb stairs? .............................................................................................Yes q No

q Can you get on and off a bus without assistance? .......................................................Yes q No

q Do you use crutches?....................................................................................................... Yes q No

q Do you use a walker?....................................................................................................... Yes q No

q Do you use a wheelchair?.............................................................................................Yes q No q If yes, do you own your own wheelchair?........................................................... Yes q No q If yes, will you be bringing a wheelchair with you? ..............................................Yes q No q

Note: only manual wheelchairs are permitted on this trip or can be accommodated. I f t ravel ing with your wheelchair , what are the d imensions of your wheelchair when folded?

Height: Depth: Width: ________________ Please briefly share what prompted you to apply to join us on the Pilgrimage?

DOCTORS’ INFORMATION: Please list the physicians you are seeing now, and/or have seen recently:

Name: Specialty: ____________________________________

Phone:

Name: Specialty: ____________________________________

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Phone:

Please include with this completed application the original, completed and signed Lourdes Medical Evaluation Form (attached) from your treating physician(s) regarding your current health condition, medications and treatments, and his or her assessment of your abil ity to travel overseas with us on this pilgrimage. PARISH/CHURCH INFORMATION:

Name of Parish/Church: City:

Pastor: _______________________________________

THIS SECTION MUST BE COMPLETED AND SIGNED FOR YOUR APPLICATION TO BE CONSIDERED.

I, , agree to be interv iewed by des ignated Warr iors to Lourdes P i lgr image Medica l Team Members. I f requ ired, I a lso agree to be examined by doctors and/or nurses from that team. I give permission to the members of the medical team to contact my doctor(s), health care provider(s) and pastor to obtain information on my condition.

Further, I attest that I have given my health care provider(s) and pastor my permission to release information to the Warriors to Lourdes Pilgrimage Medical Team (I may use the attached Protected Health Information Release Authorization Form, or a similar form, to authorize my doctor[s] and any other health care provider[s] to release information to designated Warr iors to Lourdes P i lgr image Medica l Team Members).

My signature below also indicates that I understand the rigors of the trip, that I have truthfully completed this application and that I have fully informed the AMS and the KofC, by way of this application, of my complete medical condition.

I agree to assume responsibility for all professional medical care that I may require during this trip. Signature Date

Please complete (print or type) answers to all questions above and ship the original, completed and signed forms (applications must be signed by both the pilgrim applicant and companion-caregiver applicant) via U.S. Mail, UPS, FEDEX, etc. with all supporting materials. Applications and materials must be received by Friday, Jan. 10, 2014, to:

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

If you have any questions concerning this application, please call (203) 752-4633, or email Lourdes@KofC.org.

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2014 AMS-KofC Warriors to Lourdes Pilgrimage Application Protected Health Information Release Authorization Form

This authorization is made pursuant to the Health Insurance Portabil ity and Accountabil ity Act (HIPAA) and any other applicable federal or state laws. By completing this form, I am voluntarily authorizing the health care provider(s) named below to disclose information, including protected health information, regarding my current and past health condition and treatment to AMS-KofC Medical Team Members for the purposes of my applying for the opportunity to make, and if selected, making, a pilgrimage to Lourdes, France. Such information may include medical records and/or conversations or consultations between AMS-KofC Medical Team members and my health care provider(s).

Applicant Name:

Address: _______________________________________________________________________________________

City, State, ZIP: ___________________________________________________________________________

Telephone: ________________________________ Date of Birth: _____________________________

Health Care Provider(s) that I Authorize to Disclose Protected Health Information

Provider Name/Contact:

Address: _______________________________________________________________________________________

City, State, ZIP: ___________________________________________________________________________

Telephone: _______________________________________________

This authorization wil l expire after the completion of the 2014 AMS-KofC Warriors to Lourdes Pilgrimage (on or about June 1, 2014).

• I understand that I have the right to revoke this authorization, at any time, in writing. • I understand that a revocation is not effective to the extent that any person or entity has

already acted in reliance on my authorization. • I understand that my treatment, payment, enrollment, or eligibil ity for benefits, as related to

my health care provider, wil l not be conditioned on whether I sign this authorization. • I understand that information used or disclosed pursuant to this authorization may be disclosed

by the recipient and may no longer be protected by federal or state law.

Applicant Signature: ________________________________________________________________________ (If personal representative is signing, please provide documentation regarding relationship and authority)

You may use a copy of this form (or one similar to it) to authorize your health care provider(s) to disclose your health records and/or information regarding your medical condition to an AMS-KofC Medical Team Member.

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Print Name: ______________________________________ Date: _____________________________

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Application for the 2014 Archdiocese for the Military Service (AMS) and Knights of Columbus (KofC) Warriors to Lourdes Pilgrimage

May 13-19, 2014

Companion-Caregiver Application Not all wounded or disabled military pilgrims require a companion-caregiver. Companion-caregivers are normally a spouse, family member, relative or close friend who knows the pilgrim well and is very familiar with the physical and mental requirements of the pilgrim. A companion-caregiver is often required to assist the wounded or disabled military pilgrim with basic care needs, including but not limited to: bathing/personal hygiene, dressing, sitting, standing, feeding, and dosing/timing of prescribed medications. A companion-caregiver must be in good health, capable of sitting and/or standing in place for extended periods, walking long distances (up and down stairs, hills and on uneven surfaces) and cannot have physical limitations that will prevent them from properly assisting the pilgrim. A completed Companion-Caregiver Application must be submitted at the same time as the Wounded or Disabled Military Personnel Application (for all companion-caregivers that will be traveling with the wounded or disabled military pilgrims, if selected).

PERSONAL INFORMATION Legal Last Name: __________________________________ Legal First Name: ______________________________ Nickname: _____________________________________ Gender: Male q Female q Home Address: _________________________________ City: ________________ State: _____ ZIP: _________ Preferred Phone Number: ___________________________ Email Address: ________________________________ Marital Status: _______________________ Name of Spouse (if married): _________________________________ Name of the wounded or disabled military pilgrim you are accompanying: ___________________________________ Emergency Contact Information (Your emergency contact should NOT be traveling on the pilgrimage. Suggest a family member or other individual in the United States to be contacted in case of an emergency.)

Name: ________________________________________ Relationship: _______________________________

Telephone: (home) _____________________________ (work) _____________________________________

Telephone: (mobile) _______________________________ Email: ____________________________________ AIR TRAVEL AND PASSPORT INFORMATION NOTE: Passports must be valid through Nov. 20, 2014 (6 months post return date) Name:

(full legal name as it appears in your passport including first, middle & last name)

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Passport Number: ________________________________ Nationality:

Expiration Date: _________________________________ Date of Birth: _______________________________ Alien Registration Number (if applicable): Do you have any difficulties with long airplane rides? ....................................................Yes q No q If yes, please explain: Seat Request (entire flight is coach): q Window q Midd le q Ais le Mea l Requ i rement: S tandard q Spec ia l D ie t q (p lease spec i fy : ) (Please note: All attempts will be made to accommodate these requests, but they cannot be guaranteed.) MEDICAL INFORMATION Are you current ly under a phys ic ian 's care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q Please list the conditions and durations for which you are under care (add additional information on a separate paper, if necessary):

Name of your Physician: ________________________________ Telephone: Please list all of your medications and include condition, dosage and schedule. Please attach a listing in this format if additional space is necessary. Important note: Medical marijuana is prohibited on any international flight and is illegal in France. Medication Condition Dosage Schedule

                                                               

Do you have any food and/or drug a l lerg ies?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q If yes, please explain: _____________________________________________________________

Do you have any limitations in performing your own personal activities of daily living?.... Yes q No q If yes, please explain:

What is your current height, weight and age? Height: ________ Weight: ________ Age: ________

Questions Related to the Role of Companion-Caregiver What is your relationship with the military applicant?_______ __________________________________ Are you capable of assisting your pilgrim with his/her activities of daily living? . . . . . . . . . . . .Yes q No q Do you help the applicant to use the toilet regularly?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes q No q Do you help with or bathe the applicant regularly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q Do you l i f t the app l i can t in to and ou t o f bed each day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q

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Do you prepare meals for the applicant regularly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q Do you admin is ter medicat ions/dosage for the app l icant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q Do you help the applicant change bandages, catheters or any other medical devices?. . . . .Yes q No q Do you accompany the app l icant on regu lar or extraord inary doctor ’s v is i ts? . . . . . . . .Yes q No q Can you l i f t and t ransfer the appl icant by yourse l f? ….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes q No q

Briefly share how you believe the pilgrimage to Lourdes will benefit the pilgrim that you are asking to accompany?

My signature below indicates I understand the rigors of the trip and agree to take responsibility to care for the wounded or disabled military applicant throughout the 2014 AMS-KofC Warriors to Lourdes Pilgrimage. Further, my signature below attests that I have truthfully informed the AMS-KofC, by way of this application, of all medical conditions I have. I agree to be interviewed by the AMS-KofC Warriors to Lourdes Pilgrimage Team. In addition, I agree to assume responsibility for all professional medical care that I may require while on this trip.

Signature Date

Please complete (print or type) answers to all questions above and ship the original, completed and signed forms (applications must be signed by both the pilgrim applicant and companion applicant) via U.S. Mail, UPS, FEDEX, etc. with all supporting materials. Applications and materials must be received by Friday, Jan. 10, 2014, at the following address:

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

If you have any questions concerning this application, please call (203) 752-4633 or email Lourdes@KofC.org.

For general information about the 2014 Warriors to Lourdes Pilgrimage, please visit our website at: WarriorstoLourdes.com

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PHYSICIAN EVALUATION OF MEDICAL CONDITION(S) AND CARE REQUIREMENTS for 2014 AMS-KofC

WARRIORS TO LOURDES PILGRIMAGE APPLICANTS NOTE: ALL QUESTIONS MUST BE ANSWERED.

INSTRUCTIONS

Warriors to Lourdes Pilgrimage applicants will complete page 1, and the treating/attending physician will complete and sign pages 2–6 of this medical evaluation form. The original medical evaluation forms, completed and signed, will be submitted as part of the completed 2014 Application Packet (per the Application Checklist) by Friday, Jan. 10, 2014.

_____________________________________________________________________________________ Full Name of Wounded or Disabled Military Applicant Date of Birth _____________________________________________________________________________________ Address Preferred Phone _____________________________________________________________________________________ City State ZIP _____________________________________________________________________________________ Sponsor’s Name Sponsor’s Phone # _____________________________________________________________________________________ Sponsor’s City Sponsor’s Region

 

If you or your physician have any questions with regard to the Medical Evaluation Form, please contact the Pilgrimage Medical Director, Dr. Greg Jolissaint, MD

(Cell Phone: (757) 969-0145 / Email: gjollysaint@hotmail.com) or the Pilgrimage Chief Nurse, Debby Jolissaint, RN (Home Phone: (410) 305-8481).

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

Name of Patient: ______________________________________

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HISTORY OF PRESENT ILLNESS

General Description of Injuries or Disabilities:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Associated Medical or Surgical Conditions:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Medications:

Please list all of your medications and include condition, dosage and schedule. Please attach a listing in this format if additional space is necessary. Important note: Medical marijuana is prohibited on any international flight and is illegal in France. Pilgrims must not bring medical marijuana on the trip.

Medication Condition Dosage Schedule

               

               

               

               

               

               

               

Name of Patient: ______________________________________

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Allergies (pertains to both medication and food allergies):

_________________________________________________________________________________

_________________________________________________________________________________

DETAILED REVIEW OF SYSTEMS

1. CARDIOVASCULAR: Problem: No _____ Yes _____ If yes, check all that apply: Chest Pain _____

Shortness of Breath _____ Palpitations _____ Swelling of Lower Extremities _____ Blood Pressure _____

Stroke _____

Comments: __________________________________________________________________________________

2. RESPIRATORY: Problem: No _____ Yes _____ If yes, check all that apply: Cough _____

Shortness of Breath _____ Abnormal Sputum _____

Other: ___________________________________________________________

3. HEARING: Problem: No _____Yes _____ If yes, describe:

_____________________________________________________________________________

4. VISION: Problem: No _____ Yes _____ If yes, describe:

_____________________________________________________________________________

5. GASTRO-INTESTINAL: Problem: No _____ Yes _____ If yes, check all that apply: Pain _____

Nausea _____ Vomiting _____ Ileostomy _____ Colostomy _____

Other: ____________________________________________________________

6. BOWEL: Problem: No _____ Yes _____ If yes, check all that apply:

Constipation _____ Diarrhea _____ Incontinence: Frequent _____ Occasional _____

Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________

Name of Patient: ______________________________________

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Comments: _________________________________________________________________________________

7. URINARY: Problem: No _____ Yes _____ If yes, check all that apply: Frequency _____ Pain _____

Incontinence: Frequent _____ Occasional _____ Bedwetting _____

Assistive devices: Catheter _____ External _____ Indwelling _____

Other: _____________________________________________________________________________________

Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________

Comments: _________________________________________________________________________________

8. NUTRITION: Problem: No _____ Yes _____ If yes, describe: ________________________________________

Level of nutritional care needed: _________________________________________________________________

Special Diet: No _____ Yes _____ Specify: _______________________________________________________

Needs to be fed: No _____ Yes _____

Comments: __________________________________________________________________________________

9. NEUROMUSCULAR Problems: Check all items that apply:

Ambulatory _____

Ambulatory with Limitation _____ Non-ambulatory _____

Amputation: No _____ Yes _____ If yes, describe: _____________________________________________

Paralysis: No _____ Yes _____ If yes, describe: ___________________________________________________

Seizures: No _____ Yes _____ If yes, type: _________________________ Frequency: __________________

Significant limitation of motion: No _____ Yes _____ If yes, describe: __________________________________

Supportive devices: Cast _____ Bandage _____ Brace _____ Describe: _________________________________

Comments: _________________________________________________________________________________

10. HYGEINE / GROOMING: Level of care needed:

________________________________________________________________________________________

Bathing: Self _____ Assistance: Total _____ Partial _____

Dressing: Self _____ Assistance: Total _____ Partial _____

Hair: Self _____ Assistance: Total _____ Partial _____

11. PSYCHIATRIC: Problem: No _____ Yes _____ If yes, specify: _______________________________

___________________________________________________________________________________

Anxiety: _____________ Depression: _____________ Mood Swings: _____________ Irritability: _____________

Name of Patient: ______________________________________

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12. SKIN: Problem: No _____ Yes _____ Pressure Sores _____

Describe: ___________________________________________________________________________________

PHYSICAL EXAMINATION

Height: _______________ Weight: _______________ Blood Pressure: ______________

Ears: Normal r _____________________________________________________________

Eyes: Normal r _____________________________________________________________

Nose: Normal r _____________________________________________________________

Throat: Normal r _____________________________________________________________

Lungs: Normal r _____________________________________________________________

Heart: Normal r _____________________________________________________________

Abdomen: Normal r _____________________________________________________________

Genitalia: Normal r _____________________________________________________________

Rectal: Normal r _____________________________________________________________

Skin: Normal r _____________________________________________________________

Extremities: Normal r _____________________________________________________________

Comments: _____________________________________________________________________________________

_______________________________________________________________________________________________

Diagnosis/Diagnoses:

_____________________________________________________________________________________

_____________________________________________________________________________________  

_____________________________________________________________________________________  

_____________________________________________________________________________________

Specific Nursing Care Requirement(s): NONE r

_____________________________________________________________________________________

_____________________________________________________________________________________

I understand this patient will be in Lourdes, France, May 14-19, 2014 Yes _____ No _____

Is this patient medically stable to travel to Lourdes, France? Yes _____ No _____

Will this patient require the use of a portable oxygen canister? Yes _____ No _____

Name of Patient: ______________________________________

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Will this patient require the use of any electrical device? Yes _____ No _____

Do you anticipate this patient requiring professional medical/nursing services or hospitalization during travel to/from Lourdes, France, or during the week of the pilgrimage in Lourdes, France?

Yes _____ No _____

GENERAL INFORMATION

Does this individual have difficulty walking long distances? Yes _____ No _____

Can this individual sit in a standard coach airline seat for a 9-hour flight? Yes _____ No _____

Does this individual speak English? Yes _____ No _____

ALL QUESTIONS MUST BE ANSWERED.

_____________________________________________________________________________________ Physician’s Signature Print Physician’s Name Dated  

_____________________________________________________________________________________ Physician’s Address

 

_____________________________________________________________________________________ Physician’s Phone # Physician’s Fax Mobile/Pager

 

_____________________________________________________________________________________ Physician’s Email Address

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

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Pilgrimage Release of All Liability Agreement Archdiocese for the Military Services (AMS) and Knights of Columbus (KofC)

2014 Warriors to Lourdes Pilgrimage Printed Name (as it appears on passport): _______________________________________

Status during Pilgrimage (circle one): Wounded or Disabled Military Personnel/ Companion-Caregiver / Volunteer

Agreement

I acknowledge that I have voluntarily applied to attend the 2014 AMS-KofC Warriors to Lourdes Pilgrimage (hereafter referred to as “the Pilgrimage”) that will be conducted in Lourdes, France, May 13-19, 2014, and to engage in all scheduled activities associated with the Pilgrimage. I am aware that participating in the Pilgrimage and its activities involves a risk for injury to my person and my property. I voluntarily accept all risk of personal injury and property damage arising from my attendance and participation in the Pilgrimage. I understand that neither the Archdiocese for the Military Services (AMS) nor the Knights of Columbus (KofC) undertakes responsibility for my medical care during the Pilgrimage, nor while traveling to or from the Pilgrimage. As lawful consideration for being permitted to attend the Pilgrimage and to participate in its activities, I hereby agree that I, my heirs, my personal representatives, and my assigns will not make a claim against nor sue the AMS or the KofC, their officers, directors, medical and non-medical volunteers, or agents for any injury or damage arising from negligence or other acts, however caused. In addition, I hereby release, discharge and hold harmless the AMS or the KofC, their officers, directors, employees, medical and non-medical volunteers, or agents from all actions, claims (including malpractice claims) or demands that I, my heirs, personal representatives, or assigns may have for injuries or property damage or any other loss or damage of any kind, including without limitation all consequential damage resulting from my attending the Pilgrimage or participating in its activities. I agree that this release includes injury or damage caused in whole or part by the negligence of the AMS or the KofC, their officers, directors, medical and non-medical volunteers, or agents. This Pilgrimage Release of All Liability Agreement does not relieve the AMS or the KofC,

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their officers, directors, volunteers or agents from liability arising from acts of wanton and willful misconduct. This agreement applies to all travel in connection with the Pilgrimage (and travel to and from Lourdes, France), whether by aircraft, railroad, motor coach, bus, private car, boat or any other means of transportation. It also applies to any loss or damage which directly or indirectly results from acts of God, acts of government or state authorities de jure or de facto, including but not limited to war, civil disturbances, strikes, riots, terrorism, theft, acts of violence, epidemics or any other causes beyond the control of the AMS or the KofC. This agreement is for the benefit of the AMS and the KofC, their officers, directors, employees, volunteers (medical and non-medical) and agents. Third parties, such as common carriers and hotels, are not released from their liability for their acts by this Agreement. I am aware that there may be limits upon the liability of such third parties arising from international conventions or other laws, and that I may be able to obtain additional protection by purchasing traveler’s insurance from a private company — such insurance is not affected by those limitations of liability. I have carefully read this two-page agreement. I understand that it is a complete release of liability and that I am making a promise to not sue or to make a claim (to include malpractice claims against Pilgrimage medical volunteers). I am aware that it is a contract between the AMS, the KofC, and me.

Printed Name (as it appears on passport): ___________________________________ Signature: ____________________________________________ Date: _____________________________  

APPLICANTS, ONCE YOU COMPLETE YOUR APPLICATION AND OTHER REQUIRED DOCUMENTATION, YOU MUST

MAIL THE ORIGINAL DOCUMENTS TO THE ADDRESS LISTED BELOW. HOWEVER, WE STRONGLY

RECOMMEND MAKING A “FILE COPY” OF THE DOCUMENTATION BEING SUBMITTED PRIOR TO MAILING THE

DOCUMENTS TO US (IN CASE THEY SOMEHOW GET LOST IN THE MAIL).

2014 AMS-KOFC WARRIORS TO LOURDES PILGRIMAGE

APPLICATION PACKET CHECKLIST (CHECK ALL APPROPRIATE BOXES)

r I HAVE MADE A “FILE COPY” OF ALL DOCUMENTATION BEING MAILED TO THE KNIGHTS OF

COLUMBUS

r I HAVE INCLUDED MY COMPLETED AND SIGNED WOUNDED OR DISABLED MILITARY PERSONNEL

APPLICATION

r I HAVE INCLUDED MY COMPLETED AND SIGNED PHYSICIAN EVALUATION OF MEDICAL

CONDITION(S) AND CARE REQUIREMENTS

r I HAVE INCLUDED MY SIGNED PROTECTED HEALTH INFORMATION RELEASE AUTHORIZATION

FORM

r I HAVE INCLUDED A COMPLETED AND SIGNED COMPANION-CAREGIVER APPLICATION

r I HAVE INCLUDED A COMPLETED AND SIGNED PILGRIMAGE RELEASE OF ALL LIABILITY

AGREEMENT

r I HAVE INCLUDED A SIGNED LETTER OF ENDORSEMENT FROM PRIEST/CHAPLAIN SPONSOR MAILING ADDRESS FOR ALL ITEMS BEING MAILED TO THE KNIGHTS OF COLUMBUS:

Knights of Columbus Attn: 2014 AMS-KofC Warriors to Lourdes Pilgrimage

78 Meadow St. New Haven, CT 06510

Requirements for Sponsoring Chaplain/Priest Endorsement

The following represents the items that the sponsoring Chaplain/Priest should include in the Endorsement Letter for 2014 Warriors to Lourdes Pilgrimage Applicants:

1. Standard Letterhead for the Chaplain/Priest

2. Date of endorsement

3. Wounded or disabled military applicant’s full name

4. Length and type of relationship with the applicant (Unit Chaplain; Parish Priest; friend; etc.)

5. Assessment of applicant’s spiritual motivation to fully participate in all Lourdes pilgrimage activities during the May 2014 pilgrimage to Lourdes

6. If appropriate, an assessment of the applicant’s financial need for assistance in order to attend the 2014 pilgrimage to Lourdes, France

7. Email and telephonic contact information in case a member of the Pilgrimage Planning/Medical Team needs to contact the Chaplain/Priest for additional information

8. Signature block and original signature of Chaplain/Priest