Parental Consent and Emergency Medical Release Form Catholic Diocese of Austin
St. Ignatius Martyr Catholic Church Life Teen Youth Ministry
July 1, 2017 thru June 30, 2018
I/We, the parent(s)/guardian(s) of (Name of Youth)
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do hereby give my/our permission and approval for my/our son/daughter/guardianship to participate in the event named above on date named above. I/We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone any events related to this event, other participants, staff and volunteers, St. Ignatius Martyr Catholic Church, the Catholic Diocese of Austin, the Bishop, the Diocese of Austin Office of Youth, Young Adult & Campus Ministry, Eagle's Wings Retreat Center, the University of Notre Dame, Six Flags, Community First! Village, Life Teen as well as any other facility, group or organization that my child may participate with during Youth Ministry and the staff and any of the above named parties’ representatives, successors, supervisors, sponsors, and/or organizers, for any injuries in connection with any event(s)/activities named above, provided that said injuries are not the result of gross, willful negligence.I/We likewise release from liability any person(s), airline, bus company, or other transportation service, transporting my child, 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. I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/ guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child as deemed medically necessary. Unless otherwise instructed, it is permissible that my/our son/daughter/guardianship be given aspirin I pain medication I cold medicine by either medical personnel or other adults responsible during this event.I/We also agree that I/we am legally responsible for all/any personal actions taken by my/our child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/ behavior of my child/guardianship. If you agree, please type in your FULL NAME & TODAY'S DATE below.
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Behavior Release: I/we agree that if the above named student's behavior is inappropriate, unsafe and/or detrimental to the group, I/we will be contacted immediately to secure means of removing my/our child/guardianship from the event premises. Rules for Youth Ministry include, but are not limited to, items listed in the Youth Participant Agreement. I/we understand that any financial costs incurred as a result of my/our child/guardianship being sent home are my/our responsibility.
Promotional Release: I/we give consent to the use of any video, photographs, slides, audiotapes, or any other visual or audio reproduction for my/our son/daughter/guardianship during event(s)/activities associated with St. Ignatius Martyr Youth Ministry. I/we understand that said photos/videos may be used for future publicity for St. Ignatius Martyr, the Diocese of Austin, St. Ignatius Martyr Youth Ministry (Life Teen or Edge) and or Catholic Church in print, audio, social and other media forms.
Social Media Release: I/we give permission for St. Ignatius Martyr Youth Ministry and adults involved in Youth Ministry to communicate with my son/daughter/guardianship using Facebook, Instagram, Twitter, and other social media. I understand that I may request access to the social media sites, and any other communication at any time.
St. Ignatius Youth Participant Agreement: In signing the line below, I agree to abide by any/all policies and rules established for these events/activities, including but not limited to the specific rules set forth by St. Ignatius Martyr Youth Ministry. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the event/activity, being sent home at my parent's expense and/or having my parent/ guardian be required to be a chaperon. Basic rules/expectations include, but are not limited to, the following: Respect for all adult leaders, peers, and all property;NO use of cell phones, iPod or other electronic devices unless given specific permission. NO illegal drugs, alcohol, smoking, firearms, explosives, or other illegal substances; No inappropriate physical/sexual activity; Appropriate attire is to be worn at all times. Other guidelines may be set forth accordingly by adult chaperons present for the event(s). (If Youth agree, please type THEIR NAME AND TODAY'S DATE.)
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YOUTH DATE OF BIRTH
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YOUTH ADDRESS
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YOUTH PHONE #
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Parent/Guardian Name and Phone #
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Parent/Guardian Name Cell Phone #
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Parent/Guardian Name Work Phone #
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Parent/Guardian Home Address
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Parent/Guardian Place of Business Address
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In Case of Emergency Contact Name , Relationship, and Phone #
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Health Insurance Identification Number
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Health Insurance Group Number
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Health Insurance is provided by which parent/guardian and/or place of employment?
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Health Insurance Address and Phone Number of Company
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A photocopy of the Insurance Card must be provided for church to file each year and/or at the time of an insurance change.
Medication (and dosage) my son/daughter is currently taking:
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Physician's Prescription or Parent Note providing instructions must accompany all medications.
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Please list any special needs or special considerations (allergies, medical/health conditions, life issues to be aware of, dietary restrictions, etc.):
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