Pilgrimage Medical & Emergency Release Form

Pilgrimage Group Leaders should make copies of this form and have each participant
bring his/her signed form to the Pilgrimage.  Individuals will not be able to participate
in Pilgrimage programs without a signed release form. We will keep each form on file.

Name of Participant: _________________________________________________

Street Address: _______________________________________________________

City: __________________________________ State: ________________________

Telephone: _________________________________

Each Pilgrimage participant must read and sign the following:

In consideration of the acceptance of my registration, for myself, my executors, administrators, and assignees do hereby forever release and discharge The Pilgrimage, of Church of the Pilgrims (PCUSA), and all other affiliates, sponsors, and subsidiaries of all claims and damages, demand and actions whatsoever in any manner arising out of my participation in The Pilgrimage programs.

I attest and verify that I have full knowledge of the risks involved in this event, and I am physically fit to participate in Pilgrimage programs. Further, I hereby grant full permission to any and all of the foregoing pictures, recordings, and any other record of this event for legitimate purposes (i.e. Pilgrimage web site) without compensation or renumeration.

Signature of Participant: ___________________________Date:__________________

Signature of parent/guardian (if participant is under the age of 18):

________________________________________________Date:__________________

Edited 11/02

RS