CATHOLIC ARCHDIOCESE OF PERTH. Pilgrim Forms. For those attending World Youth Day 2016 in Krakow from Perth Archdiocese & Bunbury Diocese.

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1 CATHOLIC ARCHDIOCESE OF PERTH Pilgrim Forms For those attending World Youth Day 2016 in Krakow from Perth Archdiocese & Bunbury Diocese.

2 ABOUT WORLD YOUTH DAY 2016 World Youth Day 2016 (WYD2016) will be held in Krakow, Poland from July. The Catholic Archdiocese of Perth (Archdiocese) is offering young people (Pilgrims) an opportunity to attend WYD2016 (Pilgrimage) through three tours being offered by Cosmos which has been named by the Australian Catholic Bishops Conference as the Official Tour Operator for Australia and New Zealand for WYD2016. There are three possible tours (Tour) Pilgrims can choose from as follows: Tour Tour Code Rome to Poland for World Youth Day Poland 19 days Following St John Paul II to WYD Krakow Poland 18 days (incl Bunbury Diocese) Celebrating St John Paul II & WYD Krakow All details of the above Tours, including; prices, maps, itineraries, inclusions and recommendations regarding insurance can be found at A copy of the Booking Terms and Conditions is available on the same website. Cosmos will be responsible for all travel, accommodation and logistics associated with the Pilgrimage. All Tour costs will be paid by Pilgrims directly to Cosmos and not to the Archdiocese. The Perth Archdiocese will coordinate group leaders, along with chaplains and staff to assist you during the Pilgrimage. Please note that the Pilgrimage is open to Pilgrims over the age of 18 but those Pilgrims aged must be accompanied by an adult parent or guardian. All Pilgrims must agree to the Cosmos Booking Terms and Conditions (part of the online registration) and to the matters contained in these Pilgrim Forms (including the Pilgrim Code of Behaviour and the matters set out under Authorisation ) in order to participate in the Pilgrimage. Please complete the attached forms and return to the Catholic Youth Ministry office (at the address below) as soon as possible so we can process your forms. If you have any further queries regarding this letter, please don t hesitate to contact: Anita Parker Director of CYM Perth Catholic Archdiocese of Perth Catholic Pastoral Centre 40A Mary Street, HIGHGATE WA 6003 Ph: E: anita.parker@perthcatholic.org.au 2 P a g e

3 GENERAL INFORMATION PILGRIM DETAILS Pilgrim Name: Mobile: Parish/Group/Movement: Employment/Study: University/Workplace: Age (as at 13 th July 2016): Date of Birth: T-shirt Size: Tour package booked: Passport number: Expiry Date: Passport country: Travel insurance details: (please include a scanned copy of your insurance certificate this can be added later) PERSONAL SKILLS OR ABILTIES To assist us in actively utilising the gifts of the group, please indicate what skills or abilities you have to share whilst on pilgrimage: First Aid Certificate Media skills (Blogging, video, journalism) please outline: Trained altar server/acolyte Extraordinary Minister of the Eucharist Polish Speaker Musician or singer - please outline details: Bronze Medallion Other skills able to assist the pilgrimage group: 3 P a g e

4 PILGRIM CODE OF BEHAVIOUR In attending World Youth Day in Krakow, and participating in its associated pilgrimages, pilgrims must be prepared to accept responsibility for their actions and acknowledge their responsibilities. All pilgrims are invited to read, consider and agree to the following expectations in order to confirm a place in the World Youth Day pilgrimage. Any pilgrim under the age of 18 must have this document countersigned by a legal guardian. As a pilgrim my conduct will be characterised by common sense, honesty, politeness, gratitude and cooperation. I will: respect the culture of the countries I visit, paying particular attention to local law and social/religious sensitivities; show respect for the practices, customs and property of others; ensure that my dealings with others will be respectful, supportive and consistent with Christian values; dress appropriately for each situation and be aware of cultural sensitivities, particularly regarding religious sites; engage in all pilgrimage activities. participate in all briefing, sharing and debriefing sessions; pay for my personal purchases and expenses, and be responsible for my personal belongings; avoid risk taking behaviour which could compromise the health and safety of myself or other pilgrims; refrain from inappropriate sexual conduct, including harassment. refrain from violence towards Pilgrims, leaders and all other persons. refrain from dangerous, demeaning, threatening (including bullying & harassment) or immoral behaviour; refrain from the drinking of alcohol if under the age of 18 and, if over the age of 18, consuming alcohol in moderation only; not using or possessing illicit and/or illegal drugs or items deemed dangerous to myself or others. observe the requirements of each location, particularly site specific rules and protocols. ensure that I am punctual and show responsibility to meeting scheduled times; respectfully follow all procedures, protocols and directions established by my Pilgrim Group Leader and Bus Leader; report incidents and accidents to my Pilgrim Group Leader, including situations which make me feel uncomfortable; not engage in outings unless I have the permission of my Pilgrim Group Leader; adhere to all advice provided to me prior to and during the pilgrimage which addresses cultural, health and security issues. This includes: personally packing, securing and having knowledge of my own luggage; reporting any new injury/illness, or change to an existing medical condition, to my Pilgrim Group Leader; not sharing any medications that I take with me or purchase on the pilgrimage, with any other person; not sharing any object (syringes, razors, toothbrushes, other personal hygiene items and grooming aids) that may come into contact with blood or other bodily substances. I understand that my behaviour must be of the highest standard and consistent with the expectations, values and beliefs of CYM Perth. I also understand and accept the authority of the organisers of the pilgrimage and my Pilgrim Group Leaders. I acknowledge that if my behaviour is not acceptable, and that there is a serious breach of the stated expectations, I may face dismissal from the pilgrimage, and return to Australia at my expense. I understand and agree to the above expectations. Pilgrim name: (Please print) Signature Date For parent/guardian of under 18 pilgrims: I have discussed these expectations with my child and I offer my full support. Parent/Guardian name: (Please print) Signature Date 4 P a g e

5 IF UNDER 18 Please meet with the Director of CYM Anita Parker before completing the guardianship form to ensure both the family & guardians understand their agreement and obligations. PARENT/ LEGAL GUARDIAN OF UNDER 18 PILGRIM I consent to my child participating in the Pilgrimage. I understand that my child must be accompanied by an adult parent or legal guardian. Select option from below: 1. I will attend the Pilgrimage with my child; or 2. I authorise (insert name) to attend the Pilgrimage as my child s guardian. (insert name) has signed this form below confirming consent to act as my child s guardian for purposes of the Pilgrimage. I accept that my child is to abide by the code of behaviour outlined above. I have signed my child s Medical Information Consent Form. SIGNED: DATE: / / NAME [Please Print]: If the Pilgrim s parent is not attending the Pilgrimage, the adult guardian nominated by the Pilgrim s parent above to attend the Pilgrimage must complete the box below and sign where indicated. I agree to attend as (insert child s name) s guardian during the Pilgrimage. I accept all responsibility for (insert child s name) during the Pilgrimage. I have given a copy of my WA current Working With Children Check card to the Catholic Youth Ministry Perth office (please attach a copy) SIGNED: DATE: / / NAME [Please Print]: 5 P a g e

6 PILGRIM AUTHORISATION Please circle the appropriate words that are underlined. The following is to be signed by the Pilgrim if over 18 or by parent/guardian if the Pilgrim is aged under 18 years of age. 1. I, the undersigned, wish to /am willing for my child to participate in the Pilgrimage. 2. I understand the nature of the activities during the Pilgrimage may include, but will not be limited to, indoor and outdoor group activities, basic hotel/hostel accommodation, communal eating, socialising, traveling in motor vehicles, private cars & chartered buses, traveling in aircraft and trains and that risks may arise during these activities. 3. I indemnify and release the Archdiocese, its officers, employees, volunteers and agents against claims and losses of any kind arising out of or in connection with my/my child s participation in the Pilgrimage. I accept responsibility for payment of all expenses associated with any such claims or losses, including, but not limited to, responsibility for payment of medical expenses incurred by myself/my child. 4. My child agrees / I agree to abide by the Pilgrim Code of Behaviour set out above, the terms of this Authorisation and any rules notified to me by the Archdiocese (collectively, Rules ) from time-to-time and to participate in all aspects of the Pilgrimage. I understand that a breach of these Rules may result in the removal of my child/myself from the Pilgrimage. If my child is/i am removed from the Pilgrimage, I accept responsibility for all costs incurred, including any travel costs associated with my child s/my early return to Australia. 5. I consent to the Archdiocese filming and/or photographing me/my child (Footage). 6. I consent to the Archdiocese and its nominees using my name, image and likeness/my child s name, image and likeness and that this footage may be used by the Archdiocese for promotional, marketing or other purposes associated with the Pilgrimage. 7. I consent to the Archdiocese or its nominees without limitation using, reproducing, exhibiting, editing, adapting, compiling with other works or materials, transmitting, broadcasting, publishing and distributing the Footage in any media at its discretion. 8. I acknowledge that the Archdiocese is not obliged to publish or otherwise use the Footage or any part of it. 9. I agree that ownership of any intellectual property rights in the Footage and all works derived or created under it vest in the Archdiocese of Perth and that to the extent that any such intellectual property rights vest in either my child or me, I hereby assign those rights to the Archdiocese of Perth. 10. To the full extent permitted by law, I consent to the doing of anything in relation to the Footage that (but for the consents provided in this letter) would otherwise infringe any moral rights, performers rights or similar non-assignable personal rights that I / my child might otherwise have including but not limited to publishing the Footage without attribution and modifying/adapting the Footage. 11. I agree to execute all documents and do all things required by the Archdiocese for the purpose of giving effect to the above requirements. 12. I understand that the Archdiocese recommends that I/my child take out personal travel/accident insurance for the duration of my journey and that it is my/my child s responsibility to take out such insurance. 13. I acknowledge that the Archdiocese collects my personal information and the personal information of my child to promote the Pilgrimage. The Archdiocese may disclose this personal information to its nominees which it engages to promote the Pilgrimage. The Archdiocese is bound by the National Privacy Principles in the Privacy Act I can access, modify, or delete the personal information the Archdiocese holds about my child/ me by contacting Anita Parker (Director of Catholic Youth Ministry Perth) at the contact details set out above. 14. I agree that the laws of Western Australia, Australia govern this letter. SIGNED: DATE: / / NAME [Please Print] 6 P a g e

7 MEDICAL INFORMATION CONSENT FORM (CONFIDENTIAL) WORLD YOUTH DAY 2016 To be completed by the pilgrim or Parent/Guardian for under 18 pilgrims. Please print all responses for ease of reading Please answer honestly to allow the pilgrimage coordinators an opportunity to provide adequate support throughout the pilgrimage for any mental health or medical needs. PILGRIMS DETAILS Name: (First name) (Surname) Doctors Family Doctor s Name: Phone: Date of Birth Phone while travelling NEXT OF KIN CONTACT Name: Telephone:(Home) (Work) (Mobile) Alternate Emergency Contact: Telephone:(Home) (Work) (Mobile) I or my child has had the following vaccinations (include Year): Vaccination Year Vaccination Year Vaccination Year DTP Hepatitis A Typhoid ADT Hepatitis B Meningitis Diphtheria HIB Pneumococcal Tetanus Influenza Japanese Encephalitis Whooping Cough Poliomyelitis Yellow Fever MMR Meningococcal C HPV Measles Chicken Pox Others: Mumps Tuberculosis Others: Rubella Cholera Others: Tetanus vaccination should be within the last 10 years. If not, and your or your son/daughter receives a Tetanus prone wound, the attending medical officer may give a Tetanus injection. 7 P a g e

8 MEDICAL HISTORY (CONT) Do you or your child have any of the following: Asthma Yes No Migraine headaches Yes No Allergies Yes No Phobias Yes No Bleeding disorder Yes No Skin condition Yes No Blood pressure Yes No Sight/hearing problems (significant) Yes No Diabetes Yes No Attention Deficit Disorder (ADD/ADHD) Yes No Epilepsy, fits or blackouts Yes No Mental Health Condition Yes No Fainting Yes No Limited Mobility Yes No Heart condition of any kind Yes No Chronic Illness Yes No Other Yes No Do you or does your son/daughter have any ankle/knee/joint problems? Yes No Have you or had your son/daughter suffered any serious injuries in the last 12 months? Yes No Do you or does your son/daughter wear contact lenses? Yes No If Yes to any of the above questions, please provide details, including a suggested management plan (attach sheet if required). Are you or your child taking any medication? Yes No If Yes, please indicate bellow. Medication must remain in the original container, labelled with pilgrims name, name of prescribing medical practitioner, name of medication, dosage and administration instructions. If assistance is required administering/storing medication, this must be discussed with the pilgrim s Group Leader. Medication: Dosage/Frequency: Medication: Dosage/Frequency: Please attach any further medication information on a separate sheet. Do you consent to yourself or your son/daughter receiving paracetamol e.g. Panadol, for temporary pain relief, high temperature or fever? Yes No For Asthma or any allergenic condition, please complete the Asthma/Allergy Management Form attached 8 P a g e

9 DIETARY REQUIREMENTS As we will be travelling in foreign countries, the organisers cannot guarantee that every requirement can be accommodated at all times. If you have a condition that may result in illness, please record this on the Allergy Management Form attached. SWIMMING ABILITY Strong 50 metres unaided Average 25 metres unaided Poor 10 metres unaided Non-swimmer About the information you give us on this and the Asthma/Allergy Management Form Health information about pilgrims is sensitive information within the terms of the National Privacy Principles under the Privacy Act 1988 (Commonwealth). The Perth Catholic Youth Ministry Office collects this information to satisfy its legal obligation to discharge its duty of care to its pilgrims. This information is collected for the purposes of activities associated with the World Youth Day pilgrimages only. DECLARATION AND CONSENT I declare that the information which I have provided on this form is complete and correct and that I will notify the Perth Catholic Youth Ministry Office if any changes occur. I have completed the relevant sections. I authorise the Perth Catholic Youth Ministry Office to enable the Pilgrim Group Leaders and medical personnel accompanying myself or my child on the World Youth Day pilgrimage to be provided with the information contained in this form. In the case of a medical or dental emergency, I authorise the Pilgrim Group Leader/medical personnel (or as delegated, if necessary), where it is impracticable to communicate with me, to arrange for and permit myself or my child to be given, while participating on this activity, such medical/surgical treatment or dental treatment, including general anaesthetic, as may be deemed necessary by a duly qualified medical practitioner or dental practitioner, as applicable. I also undertake to the pay costs incurred for medical/surgical or dental attention, ambulance transport, medication/medical drugs or other costs, which may not be covered by Travel Insurance, while I or my child is on this pilgrimage. If over 18: Name of Pilgrim completing form: Signature of Pilgrim completing form: Date: IF UNDER 18: Name of Parent/Guardian completing form: Signature of Parent/Guardian completing form: Date: 9 P a g e

10 ASTHMA/ALLERGY MANAGEMENT DETAILS FOR WORLD YOUTH DAY 2016 To be completed by Pilgrim or Parent/Guardian if asthma or allergies have been identified ASTHMA Signs/Triggers Usual signs of pilgrims asthma Worsening signs of pilgrims asthma What triggers pilgrims asthma? Increased signs of: Exercise Wheezing Wheezing Colds/viruses Tightness in chest Tightness in chest Pollens Coughing Coughing Dust Difficulty in breathing Difficulty in breathing Smoke Difficulty speaking Difficulty speaking Weather changes Other (please describe) Other (please describe) Other (please describe) Asthma Medication Requirements Note: Please repeat, even if previously noted on this form. Name of medication Method (e.g. puffer and spacer, Turbuhaler, Accuhaler) When, and how much? Pilgrims Asthma First Aid Plan (Please describe) Any other information that will assist with asthma management for yourself or your son/daughter while on the World Youth Day pilgrimage? (e.g. peak expiratory flow action plan, night time asthma, recent attacks) 10 P a g e

11 ALLERGY Have you or your son/daughter suffered from the following reaction to an allergy: A localised reaction (rash, itching, swelling at the site the poison/irritant enters)? Yes No A systemic reaction (rash, itching, swelling away from the site the poison/irritant enters)? Yes No An anaphylactic reaction (severe breathing problem, total body swell, emergency situation)? Yes No Any allergic response as a result of medication administered during a surgical procedure Yes No What are you or is your son/daughter allergic to? (including foods, plants, insect bites, medications). Please describe the symptoms. Allergy: Symptoms: Treatment: Allergy: Symptoms: Treatment: Please attach a separate sheet for any further allergies. Key Questions Is there a history of anaphylaxis in your family? Yes No Have you or your son/daughter been admitted to hospital due to an allergenic reaction? Yes No DECLARATION I declare that the information which I have provided on this form is complete and correct and that I will notify the Perth Catholic Youth Ministry Office if any changes occur. I have completed the sections above. I authorise the Perth Catholic Youth Ministry Office to enable the Pilgrim Group Leaders/ medical personnel accompanying the pilgrim group to be provided with the information contained in this form. If over 18: Name of Pilgrim completing form: Signature of Pilgrim completing form: Date: IF UNDER 18: Name of Parent/Guardian completing form: Signature of Parent/Guardian completing form: Date: 11 P a g e