St. Bernard Parish - Liability Form
The following serves as your liability form for the 2017-2018 school year for any youth ministry activities for St. Bernard Parish. No paper forms will be necessary to complete because this replaces it. Only the youth ministry department of St. Bernard Parish, and, depending on the event, of the Diocese will have access to this liability form online.

This liability form covers ANY events that we do on-site or off-site at St. Bernard Parish. You simply need to complete this once during the school year.

Student's Full Name: *
Your answer
Student's Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Current grade: *
Student's T-Shirt Size: *
Student's email address: *
Your answer
Parent/Guardian's Full Name: *
Your answer
Home address: *
Your answer
Parent email: *
Your answer
Parent phone number: *
Your answer
I grant permission to participate in events organized by St. Bernard Parish parish and the Diocese of Green Bay from December 2017 to September 2018. If the event is offsite, I also grant permission for my child to be transported by any means of official transportation organized by the Diocese of Green Bay or their representatives. *
Required
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the parish listed above and the Diocese of Green Bay, its officers, directors, employees and agents, and the Diocese of Green Bay, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and Diocese of Green Bay its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of Green Bay. *
Required
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.) EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission 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. *
Required
In the event of an emergency, if you are unable to reach me at the above numbers, contact: (First and Last Name of Person) *
Your answer
Emergency Contact Number of the above person: *
Your answer
Child's Family Doctor: *
Your answer
Phone number of the Doctor: *
Your answer
Family Health Plan Carrier: *
Your answer
Insurance Policy #: *
Your answer
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:
Your answer
Please check ONE of the Following: *
Signature Verifying Medication Information Above is Correct *
Required
Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence. Does your child have allergic reactions (medications, foods, plants, insects, etc.)?
Your answer
Does your child have a medically prescribed diet?
Your answer
Does your child have any physical limitations?
Your answer
You should be aware of these special medical conditions of my child:
Your answer
MEDIA RELEASE: This authorization form constitutes permission for my child(ren)’s participation in videotaping and/or photographs which may be taken during the program/trip. These could be used for further promotional videos, website promotions, fliers, or other diocesan or parish appropriate uses. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service