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PARENTAL/GUARDIAN PERMISSION AND LIABILITY WAIVER
Participant's Name: ________________________________________________________________ Birth Date: ____________________________ Grade: _________________ Sex: _______________ Parent/Guardian's Name: ___________________________________________________________ Home Address: ___________________________________________ Zip: ____________________ Home Phone: ( ) _ ________________ Business Phone: ( ) _____________________________ Cell Phone: ( ) ______________ __ Email Address: ____________________________ _ I, ________________________, grant permission for my son/daughter, ______________________, Parent or Guardian's Name Child's Name to participate in this parish youth ministry program. This program will take place under the guidance and direction of parish employees and/or volunteers from Our Lady of Guadalupe Church.
Activity: Date(s) of Event: Fall 2008 and Spring 2009 Semesters of The Edge Middle School Youth Ministry Program On Site Telephone Number for Emergencies: 695-8791 ext. 25, unless otherwise indicated Destination: Our Lady of Guadalupe Church Parish Hall, unless otherwise indicated Individual in Charge: Sara Weir Estimated Time of Departure and Return: Varies by event; check event details for exact times Mode of Transportation to and from Event: To Be Determined by Family
As parent/legal guardian, I remain legally responsible for any personal actions taken by my son/daughter named above. I agree on behalf of myself, my son/daughter named herein, our heirs, successors, and assigns to hold harmless and defend Our Lady of Guadalupe Church, its officers, directors, agents, and the Archdiocese of San Antonio from any liability for illness, injury or death arising from or in connection with my son's/daughter's attending the above named event, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of San Antonio, or representatives associated with the event for reasonable attorney's fees and expenses arising in connection therewith.
__________________________________ Parent/Guardian Name (PRINT)
__________________________________ ___________________________________ Signature Date
MEDICAL CONSENT AND PERMISSION TO TREAT
My child is in the care of _________________________ for the purpose of this youth ministry activity: _________________________________________________________________________ I am giving medical permission and consent to treat.
To the best of my knowledge, my child, ________________________________ is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I give permission to transport my child to a hospital for emergency treatment. I wish to be advised prior to any further treatment by the hospital or doctor. Parent/Guardian's Name: ___________________________________________________________ Home Address: _________________________________________ Zip: ______________________ Home Phone: ( ) _______________________ Business Phone: ( ) _______________________ Cell Phone: ( ) __________________________
If you are unable to reach me, please contact: Name: __________________________________________________________________________ Relationship to me or my son/daughter: ________________________________________________ Home Phone: ( ) ____________________ Business Phone: ( ) _____________________________ Cell Phone: ( ) ________________
Please include a photocopy of your Insurance Card, front and back. Insurance Carrier: _________________________ Policy Number: ___________________________ My son/daughter is taking medication and will bring all medication with him/her and it will be clearly labeled. My son/daughter is taking the following medications) and directions for taking this medication, including dosage, frequency and storage are as follows: ______________________________________________________________________________ I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) to be given to my child if necessary. I understand that aspirin will not be given to my son/daughter without my express permission: I grant such permission ____Yes, ____ No.
My son/daughter is allergic to the following: _________________________________________ My son/daughter's immunizations are current and up to date ____ Yes, ____ No. My son/daughter has the following limitations: _______________________________________ My son/daughter experiences homesickness, emotional reactions to new situations, sleepwalking, fainting, bedwetting, etc. ____ Yes, ____ No. Please explain: ________________________________ ________________________________________________________________________________
Parent/Guardian Name (PRINT) _______________________________________________________
__________________________________ ___________________________________ Signature Date
MODEL RELEASE STATEMENT I hereby grant permission for my child to be photographed and/or videotaped during Edge activities and events. I understand that my child may decline to be photographed and/or videotaped at any time. I further grant permission for the resulting photographs and/or videotaped footage to be edited, if necessary, and then published and/or broadcast for the purpose of promoting The Edge and/or youth programs at Our Lady of Guadalupe Church and on our web site.
Name (PLEASE PRINT) ___________________________________________________________
Signature _____________________________________________ Date: _____________________
I hereby decline to grant permission for my child to be photographed and/or videotaped during Edge activities and events. I have instructed my child to decline to be photographed and/or videotaped at all times. I have further instructed my child to notify Edge coordinators and/or Core Team Members that he/she may not be photographed and or videotaped under and circumstances.
Name (PLEASE PRINT) ___________________________________________________________
Signature _____________________________________________ Date
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