| Child’s Name: | Parish: |
| |
| Address: | Phone: |
| |
| School: | Grade: |
Birth date: |
| | |
| Parent/Guardian Name: | Parent/Guardian Email: |
| |
| Address: |
|
| Home Phone: | Work Phone: | Cell/Alt. Phone: |
| | |
| In case of emergency, notify person other than parent/guardian: |
| Name: | Phone: |
| |
|
| Health and Medical Information |
|---|
| Family Physician: | Address: | Phone: |
| | |
| Medical Plan: | Plan #: |
| |
| Do you authorize the adult leader to authorize medical treatment for your child in an emergency, as considered necessary by attending physician? | Yes No |
| State any reasons why you DO NOT want medical care given to your child in case of emergency? |
|
| List all conditions (such as allergies, seizures) for which your child requires ongoing medication and state the type of frequency of medication given: |
|
| Has your child had any difficulty with the following? (check all that apply) |
| Asthma |
Fainting Spells |
Convulsions |
Diabetes |
Heart |
Eyes |
| Ears |
Nose |
Throat |
Lungs |
Digestion |
Menstrual |
| List any physical restriction or restriction for any activity on the basis of medical condition: |
|
| Allergy or reaction to any medication? | Yes No | List:
|
| State the date of your child’s LAST physical examination: | |
|
| Parental Permission and acknowledgement of
Conditions for Participation in Program |
- I/we agree to direct my/our child to cooperate and comply with reasonable directions and instructions from Youth Ministry staff or adult volunteer leaders.
- I/we agree to be responsible for all medical expenses relating to injury of my/our child as a result of his/her participation in any youth ministry activity, whether or not caused by the negligence of the parish, youth ministry program employees, agents or volunteers or other participants.
- I/we understand that children participating in youth ministry activities risk injury to the body, psyche or property damage to themselves and others. Such injuries can be caused by other persons or accidentally or intentionally self inflicted, faulty equipment or facilities, conditions of recreational facilities, vehicle accidents while in transport or through activity itself.
|
| RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT |
|---|
In consideration for being permitted to participate in the activities of the youth ministry program, use the equipment provided and to enter the premises or facilities of the Diocese of Oakland (Diocese) for any purpose including observation and participation in activities, the parent or guardian for him or herself and any successors in interest and on behalf of the minor child agrees:
- To release, waive, discharge and promise not to sue the Diocese of Oakland and its affiliated entities, its officers, directors, employees, agents and volunteers. (hereafter referred to as “Releasees”) from all liability for any loss or damage, and any claim or demands therefore on account of serious or mortal injury to the body, injury to psyche or property of the minor child, or undersigned parent or guardian, whether caused by negligence or other conduct by the Releasees while the minor child, parent or guardian is participating the youth ministry activities or in, upon or about the premises of the Diocese or any of its facilities or equipment.
- To indemnify and hold harmless the Releasees from any loss, liability, damage or cost it may incur due to the presence of the minor child, parent, or guardian in, upon or about the premises of the Diocese, its facilities or equipment, or while participating in any youth ministry activities whether caused by the negligence of Releasees or otherwise.
- That the parent or guardian has read the Agreement, voluntarily signs the Agreement and that no oral representations, statements or inducements apart from the contents of this written Agreement have been made.
|
| I HAVE READ THIS AGREEMENT AND UNDERSTAND EVERYTHING WRITTEN ABOVE. |
| |
| Signature of Parent or Guardian Date | Date |
| |
| Signature of Parent or Guardian Date | Date |
|
| EVACUATION FORM |
|---|
In the event of an emergency, no individual telephone communications will be possible. The evacuation plans will go into effect, but you may indicate a preference for your child. The authorities will designate possible types of evacuation in the case of emergency:
- ON SITE- children will be kept at HOLY SPIRIT under supervision. “Housing”, food and care will be provided here.
- OFF CAMPUS- dependent upon the situation, children would be assigned to a location by local authorities. Radio stations, air patrol and/or police would be the source of information.
|
| Children enrolled in Holy Spirit Faith Formation: |
| |
| |
In the event of the evacuation of Holy Spirit Faith Formation, I choose the following (check ALL that apply): (REQUIRED)
- I will pick up my children at the evacuation site.
- I give permission for my children to walk home unattended to a reunion point.
- If I do not pick my children up personally, I designate the following person(s) to act on my behalf.
|
| NAME | ADDRESS | PHONE |
| | |
| | |
If, at the time of an emergency, first aid should be administered, I authorize the following (check ALL that apply): (REQUIRED)
First Aid may be administered by a qualified person.
I authorize sending my child to a hospital, if necessary. |
| Signature: | Relationship: | Date: |
| | |
| | |