ADULT CONSENT and RELEASE FOR MEDICAL TREATMENT
In Case Of Emergency, and in the event that I am not coherent or conscious, I hereby grant John 15 or staff of St. Mary’s, permission to act on my behalf in seeking emergency medical treatment for myself in the event that such treatment is deemed necessary.

I hereby give my permission to those administering medical treatment to do so.

I further absolve and release St. Mary’s Catholic Center, its pastor, employees, and volunteers, as well as the Diocese of Austin and its employees from any liability whatsoever when acting on my behalf in regard to medical treatment, and in any other respect deemed necessary should I become incapacitated.

I do hereby absolve and release the above named for any injuries in connection with the Connect Retreat, provided that said injuries are not the result of gross, willful negligence.

I agree that I am legally responsible for all/any personal actions I take during this event and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of my actions/behavior.

I/We likewise release from liability any person(s) transporting me, in a privately owned and/or leased vehicle, to and from any activities connected with the above named event(s), with the exception of gross negligence due either fully, or in part, to mechanical failure and/or operator error.
Name of Participant *
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Address (Street) *
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City *
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State *
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Zip Code *
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Participant Phone Number *
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Social Security Number *
(Required for treatment in most hospitals)
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Insurance Company *
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Policy Number *
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Insurance Address *
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Insurance Phone Number *
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Place of employment providing insurance *
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Additional comments regarding medical history, allergies, medications, or other conditions
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