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Release and Liability Under 21

- Parish Life

Parental/Guardian Consent Form & Liability Waiver
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- Participant's Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Home Address REQUIRED Please fill out this field. Please enter valid data.
- City/Zip Code REQUIRED Please fill out this field. Please enter valid data.
- Parent(s)/Guardians(s): REQUIRED Please fill out this field. Please enter valid data.
- Home Phone REQUIRED Please fill out this field. Please enter valid data.
- Alternate Phone Please enter valid data.
- Parish or Catholic School Name REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED Please fill out this field. Please enter valid data.
- Email Address REQUIRED Please fill out this field. Please enter valid data.
- T-Shirt Size
- Please specify the Event/Date & Time/Location for this waiver REQUIRED Please fill out this field. Please enter valid data.
- I (as the parents/guardian) grant permission for my child to participate in the event listed above at the time and location listed above.
  
  In consideration of my child's participation in this event, I agree on behalf of myself, my child named herin, and our heirs, successors, and assigns to indemnify, hold harmless and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all injuries, losses or claims arising out of my child's paricipation in the event.
  
  In clicking I Agree on this form I certify that all information contained herein is true and accurate to the best of my knowledge.
  I Agree Please select this field.
- YOUTH PATICIPANT:
  
  In clicking I Agree below I agree to abide by any/all policies and rules established for this event/activity (see Code of Conduct). Should I not be able to maintain the guidelines and expecations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent's expense.
  I Agree Please select this field.
- Video/Photography Consent:
  
  As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son's/daughter's picture to be used for promotional materials (newsletter, web page, calendars, power point, video etc.) in highlighting the event.
  I Agree Please select this field.
- Medical Matters:
  
  I hereby warrant 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, Agree to only those in accordance with your wishes.
  
  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 and I understand that all financial obligations are my responsibility.
  
  In the event of an emergency and you are unable to reach me, contact:
- Name & Relationship REQUIRED Please fill out this field. Please enter valid data.
- Phone REQUIRED Please fill out this field. Please enter valid data.
- Family Doctor REQUIRED Please fill out this field. Please enter valid data.
- Phone REQUIRED Please fill out this field. Please enter valid data.
- Medications:
  
  My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:
- Medications & Dosage: REQUIRED Please fill out this field.
- Administer: REQUIRED Please fill out this field. Please enter valid data.
- I hereby DO NOT GRANT PERMISSION for medication of any type, whether prescription or nonprescription, to be administered by my child unless the situation is life threatening and emergency treatment is required. Do Not Grant Permission
- I hereby GRANT PERMISSION for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. Grant Permission
- Medical Conditions Information:
  
  (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence.)
  
  My son/daughter has:
- Has had an episode of the following or has been diagnosed: Seizures Asthma Diabetic
- Allergic reactions to the following (foods, dyes, latex etc.) Please enter valid data.
- Has had a medical surgery within the last six months?
- Still under doctor's care?
- Has a medically prescribed diet? Please enter valid data.
- The following physical limitations: Please enter valid data.
- Immunizations current and up to date:
- Date of last tetanus/diphtheria immunization Please enter valid data.
- You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc) Please enter valid data.
- Insurance Information
- Insurance Carrier Please enter valid data.
- Name of Insured Please enter valid data.
- Insurance Policy Number Please enter valid data.
- Father's Name Please enter valid data.
- Day Phone Please enter valid data.
- Mother's Name Please enter valid data.
- Day Phone Please enter valid data.
- In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and I Agree to this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.
  I Agree Please select this field.
Submit

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Release and Liability Under 21

Parental/Guardian Consent Form & Liability Waiver

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston

Office Hours

Release and Liability Under 21

St. Bernadette Catholic Church Archdiocese of Galveston-Houston

Office Hours

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston