<div> Knights of the Holy Temple <br /> </div> <div> <div></div> </div>

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March for Life cost:175.0
Payment:
- You may pay via credit card or check. Once you complete and submit the registration form, you will be directed to the payment option.
Registration cost includes:
- Chartered bus transportation and metro passes
- Lodging
- Meals
Registration cost DOES NOT include:
- Spending money
- Saturday & Sunday lunch
Registration Cancellations
- Cancellations may receive a full refund prior to January 3, 2019. Registration cancellations on and after January 3, 2019 will not be refunded.
Knight's First Name REQUIRED Please fill out this field. Please enter valid data.
Knight's Last Name REQUIRED Please fill out this field. Please enter valid data.
Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Knight's Email REQUIRED Please fill out this field. Please enter an email address.
Knight's Phone Number Please enter a phone number.
Grade Please enter valid data.
Parent/Guardian First Name REQUIRED Please fill out this field. Please enter valid data.
Parent/Guardian Last Name REQUIRED Please fill out this field. Please enter valid data.
Parent/Guardian Email REQUIRED Please fill out this field. Please enter an email address.
In case of an emergency, contact: REQUIRED Please fill out this field. Please enter valid data.
Emergency Contact Phone REQUIRED Please fill out this field. Please enter valid data.
Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
Policy Number REQUIRED Please fill out this field. Please enter valid data.
Specific Medications or Medical Needs
Permission to give: Tylenol Ibuprofen Aspirin
Permission to administer basic first aid Yes No
Chapter/Parish REQUIRED St. Joan of Arc, Kokomo St. Patrick, Kokomo Our Lady of Mount Carmel, Carmel St. Maria Goretti, Westfield St. Elizabeth Seton, Carmel Union City/Winchester St. John Vianney, Fishers St. Lawrence, Lafayette St. Mary Cathedral, Lafayette St. Louis de Montfort, Fishers All Saints, Logansport St. Charles, Peru Our Lady of Grace, Noblesville St. Alphonsus, Zionsville Other Please fill out this field.
We, the parent(s) or guardian(s) permit our son to attend the 2019 March for Life pilgrimage to Washington, D.C. being planned by the Office for Vocations on January 17-20, 2019. The purpose of this trip is: support the beauty and dignity of every human life, fraternity, education of our nation's capital and the Catholic Church.

We, as parent(s) or guardian(s) of the undersigned minor(s), hereby consent and agree to hold harmless our parish of registration and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with, our son’s participation, including the transportation necessary to participate in aforementioned activity. We understand that our son may be assigned to ride with a licensed adult driver, driving a rented or privately owned automobile or school bus, and that this assignment will be made by the aforementioned staff member.

I give my permission for my son, in case of an emergency, to be taken to a physician or hospital by either a parent in charge or by diocesan personnel. I understand that every effort will be made to contact me. If I cannot be reached, I hereby give permission to the physician selected by the parish member in charge or adult chaperone to secure proper treatment for my son.
I Agree Please select this field.
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibilities for the health of my child. Of the following statements pertaining to medical matters, select only those in accordance with your wishes.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to the Office for Vocations, its officers, directors and agents, and Diocese of Lafayette-in-Indiana, agents, representatives, volunteers and employees of either the diocese or any parish thereof, and chaperones or representatives associated with this event to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, the emergency phone number provided in the above registration will be contacted.
I Agree Please select this field.
Other Medical Treatment: In the event it comes to the attention of the Office for Vocations, its officers, directors and agents, and the Diocese of Lafayette-in-Indiana and all parishes within the diocese, and the officers, agents, representatives, volunteers and employees of either the diocese or any parish thereof, and chaperones or representatives associated with the event, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be contacted by phone.
I Agree Please select this field.
Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
Name medication(s) with concise directions
I Agree Please select this field.
Additional Medications: No medication of any type whether prescription or non-prescription may be administered to my child unless the situation is life threatening and emergency treatment is required. Yes No
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed advisable. Yes No
Registration Form Consent - Parent/Guardian First & Last Name REQUIRED
I, as parent/guardian of my son, hereby give consent to all of the information provided in the above registration.
Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

Total:

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Knights of the Holy Temple

March for Life Registration

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610 Lingle Ave. Lafayette IN 47901 (765) 742-0275	The ministries of our diocese and this website are made possible through the generosity of the Fruitful Harvest donors. Thank you!