WORLD YOUTH DAY 2005

Cologne, Germany – Aug 15-21

Please Print Clearly

Country: USA Registered with: YOUTH ARISE NORTH AMERICA

Package Option: [ ] Land ONLY Package [ ] Basic WYD / YAI Package [ ] MB Pilgrimage Package [ ] MB Pilgrimage ONLY [ ] Independent Pilgrimage

Participant’s Name: __________________________ __________________________

Last First

Address: ________________________________________________________

City: _________________________________ State: _____ Zip Code: ________________

Home PH # ___________________________ WK PH # ______________________________

Cell PH # _________________________ Email: ____________________________________

Fax # __________________________________ Date of Birth: _____________________

Disabilities? _____ Describe (If marked) __________________________________________

Allergies to Food? ___________________________ Medications? _____________________

Emergency Contact ________________________________ Relationship __________________

Ph. # __________________________________ Email __________________________________

Minors ONLY (under 18)

Traveling Parent / Guardian: ________________________ ________________________

Last First

Address (Leave blank if SAME): _______________________________________________________

City: _________________________________ State: _____ Zip Code: ________________

Home PH # ___________________________ WK PH # ______________________________

Cell PH # _________________________ Email: ____________________________________

Church / Organization Name: ___________________________________________

Group Leader’s name: (Youth Minister / Leader) _____________________________________

Church PH#: _______________________ Email: ______________________________________

Are you a Priest? ________ Other Clergy? ______ What kind? ________________________