Diocese
of
PARTICIPATION
FORM FOR YOUTH MINISTRY EVENTS SHORTER THEN 6 HOURS
Forms
will be kept on file in the Office of Youth Ministry for a period of one year
following the Event.
Event Information
Parish/School/Organization
Name:
Saint Therese Parish Event:
Destination:
Date/Time
of Departure:
Date/Time of Return: Method
of Transportation:
Participation
Cost: $
Name
of Participant:
SSN:
- -
Name
of Parent/Guardian:
Home
Telephone:
Other Contacts in case of illness or injury:
Name/Phone:
Name/Phone:
Permission of Parent/Guardian
I/We, the parent(s)/guardian(s) of
, request that he/she be allowed to participate in the Event described
above, and hereby give my/our permission for such participation. I/We give my/our permission to the sponsoring Diocese/Parish/School/Organization
to take photographs, video or digital images of Participant during the Event for
future promotional purposes.
Consent for Disclosure to
Individual Involved in the Care and Treatment of Participant
For the duration of the Event, I/We
grant to the Diocese/Parish/School/Organization and its agents the following
powers, to be used for the benefit of and
on behalf of Participant (check all that apply):
to receive any and all individually identifiable health information about
the past, present and future medical condition of Participant, including, but
not limited to, information necessary to the care and treatment of Participant
and any illness or injury Participant may have sustained;
to authorize medical care for Participant, including, but not limited to,
any and all treatment, examination, diagnosis or outpatient medical care
rendered under the general or special supervision of and on the advice of any
physician or surgeon licensed to practice medicine by the applicable licensing
body in the state in which physician or surgeon practices.
I/We understand that the Diocese/Parish/School/Organization will not be liable
to me/us or any or my/our successors in interest for any action taken or not
taken in good faith.
I/We consent to the logistics and
conditions described above, including the method of transportation.
I/We understand that as parent(s) or legal guardian(s) I/we may be responsible
for any liability which may result from the conduct of Participant at or during
the Event.
I/We understand that there is a risk of injury involved in any Youth Ministry
activity. I/We hereby release the
Diocese of Kansas City-St. Joseph, and its officers, agents, employees and
volunteers, from any liability arising from claims of any kind or nature
whatsoever in connection with Participant's participation in the Event.
/
/
/
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Signature
of Parent/Guardian
Date