PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

RETURN COMPLETED FORM TO PARISH/SCHOOL/ECCLESIASTICAL ORGANIZATION
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
Name of Minor (“Participant”):
Home Address:
Home Phone:
Business Phone:
Parent(s)/Guardian(s) Name(s):
I/we,
Parent(s) Or Guardian(s) Name
grant permission for my/our child,
Participant’s Name
to participate in this parish/school/organization activity. This activity will take place under the employees and/or volunteers
guidance and direction of
.
Our Lady of the Pines Confirmation Program
Parish/School/Organization Name (Print)
A brief description of the activity follows:
Type of event:
Location(s):
Confirmation Lock-In Retreat
Our Lady of the Pines Catholic Church
Individual(s) in charge:
Duration of activity:
Ron Roderick and Adult Chaperones
Friday evening November 13th from 6:30pm through Saturday morning November 14 at 11:30am, , 2014
Mode of transportation to and from event:
parents/guardians provide transportation to and from event
As parent(s) and/or legal guardian(s), I/we remain legally responsible for any personal actions taken by the above-named
Participant.
I/We further agree to defend, indemnify and hold harmless the Parish/School/Organization and the Archdiocese of Denver as
well as any of its affiliated agencies and their respective agents, directors, officers, employees, and volunteers from any and all
claims or demands made for damage, loss, illness or injury to the above-named Participant.
Signature:
Signature:
Parent Or Guardian
Parent Or Guardian
RISK MANAGEMENT AND INSURANCE MANUAL 2010
Date:
Date:
Appendix VII.C(1)
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
PAGE 2 OF 3
MEDICAL MATTERS
The Parish/School/Organization will take all reasonable and prudent care to see that confidentiality regarding the following
information is maintained.
I/We hereby warrant that to the best of my/our knowledge, my/our child is in good health, and I/we assume all responsibility for
the health of my/our child. I/We understand and acknowledge that any medical expenses related to illness or injury to my/our
child are not covered by any insurance program maintained by the Parish/School/Organization or the Archdiocese of Denver,
and that I/we am/are responsible for such expenses.
Emergency Medical Treatment: In the event of an emergency, I/we hereby give permission to transport my/our child to a
hospital for emergency medical or surgical treatment. I/we wish to be advised prior to any further treatment by the hospital or
doctor. In the event of an emergency, if you are unable to reach me/us at the above numbers, contact:
Name of Minor (“Participant”):
Sex:
Birth Date:
Name of Parent(s)/Guardian(s):
Emergency Phone(s):
Family doctor:
Phone:
Family Health Plan Carrier:
Policy #:
Allergic reactions (medications, foods, plants, insects, etc.):
Immunizations: Date of last tetanus/flu immunization:
Does Participant have a medically prescribed diet?
Any physical limitations?
Has Participant recently been exposed to contagious disease or conditions, such as mumps, measles, flu, chickenpox, etc.? If
so, date and disease or condition:
Other special medical conditions:
Medications: Participant is taking medication at present.
Yes
□
No
□
RISK MANAGEMENT AND INSURANCE MANUAL 2010
Appendix VII.C(1)
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
PAGE 3 OF 3
It is Participant’s responsibility to bring all necessary medications, and to ensure they are clearly labeled. Instructions from the
Participant’s family physician for these medications must be attached to this form. The instructions must include the
name, concise dosing directions, purpose of, and proper storage of and for all medications.
NOTE: Parish/School/Organization staff and volunteers WILL NOT administer ANY medications requiring the use of a syringe or
other needle delivery system. Alternate accommodations for must be made for these circumstances and the
parish/school/organization fully informed of the nature of such accommodations.
Notice: I want to be contacted in the event it comes to the attention of the parish/school/organization, its officers, directors and
agents, and the Archdiocese of Denver, chaperones, or representatives associated with the activity that Participant experiences
symptoms such as headache, vomiting, sore throat, fever, diarrhea, etc.
Yes
□
No
□
I/We hereby grant permission for the following non-prescription medication (non-aspirin products such as acetaminophen or
ibuprofen, throat lozenges, cough syrup, etc.) to be administered to the Participant, if deemed appropriate.
Yes
□
No
□
OR: No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation
is life-threatening and emergency treatment is required.
Yes
□
Signature:
Signature:
No
□
Parent Or Guardian
Parent Or Guardian
RISK MANAGEMENT AND INSURANCE MANUAL 2010
Date:
Date:
Appendix VII.C(1)