Print Form ~ Medical, Photo and Liability Release Form ~ St. Maximilian Kolbe Catholic Church June 1, 2016 thru May 31, 2017 Please return this form to the Parish Office (To be completed by Parent or Guardian – Please Print) Student's Name School Grade Birthdate / / This Medical Release Form will cover all activities of St. Maximilian Kolbe Catholic Church. When required, registration forms, permission slips, and payment for specific activities must also be turned in. Specific forms for each event will be available on the website. Please notify us if any information given below changes throughout the year. Thank you. ARCHDIOCESE OF CINCINNATI PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY (rev. 8-2013) 1. I, the lawful parent or guardian of (the "child"), give permission for my child to participate in the activity described on the Activity Information form and release from all liability and indemnify the Archbishop of Cincinnati ("the Archbishop"), both individually and as trustee for the Archdiocese of Cincinnati and all parishes and schools within the Archdiocese (the "Archdiocese"), and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost and expenses, including attorneys' fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity and further agree not to bring or prosecute or allow to be brought or prosecuted (including but not limited to prosecution through subrogation) in my name, or on behalf of my Child, any claims, lawsuits or actions against the Archbishop, the Archdiocese, and their officers, agents, representatives, volunteers and employees. 2. I further understand that my Child's participation is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, elect to participate in spite of the risks. 3. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity. 4. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel: (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the Child. (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child. 5. This power of attorney shall lapse automatically upon completion of the activity and related travel. 6. I agree that the Archbishop or his agents may use my child's portrait or photograph for promotional purposes, website and office functions and use social media and technology to communicate to my child regarding ministry related activities. (Facebook, texting, etc.)" 7. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof. I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission, Release and Medical Power of Attorney shall be effective and binding upon me, my Child, and my own and my Child's personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will. _______________________________________ Signature of Parent or Guardian Home Address ______________________ ____/____/____ Date City/State Home Phone Zip Cell/Work Phone Parent /Guardian Email Address Emergency Contact High School Student's Cell Phone # Emergency Contract Phone High School Student's Email address High School Only T-Shirt Size S M MEDICAL INFORMATION Student's Name To be completed by Parent or Guardian – Please Print Chronic Conditions (e.g. Epilepsy, diabetes) Allergies Medications Medical Insurance Company Member's Name Place of Employment Family Doctor Policy Number Home Phone Work Phone Employer Address Phone See next page for activity information. L XL 2X 3X ACTIVITY INFORMATION-Keep this page for your records! Church Agency Starting Date Ending Date Usual Location St. Maximilian Kolbe Church Faith Formation June 1, 2016 May 31, 2017 St. Maximilian Kolbe Catholic Church and Family Life Complex On-Going Programs Program or Group Usual day and time: Routine Activities: Group Leader: Ancora Twice monthly on Monday evenings Scripture study, prayer, and discussion Jo Zink, 777-4322 Program or Group Usual day and time: Routine Activities: Group Leader: Children's Choir/Cherub Choir Tuesday evenings/Wednesday evenings, Saturdays, Sundays, and as announced Weekly rehearsals and singing at Mass as announced Jeremy Helmes, 513-777-4322 Ext 103 Program or Group Usual day and time Routine Activities Group Leader Early Childhood Religious Formation of Youth (RFY) Sunday mornings during 8:00 am & 10:00 am Mass Religious Education Classes Mary Lou Baker, 513-777-4322 Ext 120 Program or Group Usual day and time Usual day and time Usual day and time Routine Activities Group Leader High School Youth - Movie Mondays, FRESH, HomeLIFE Communities Wednesday evenings: 7:00 pm – 9:00 pm; June 8th through August 3rd FRESH: 2nd and 4th Sunday evenings during the school year 7:00 - 9:00 pm, with exceptions as announced HomeLIFE Groups: 1st and 3rd Sunday evenings during the school year, with exceptions as announced Comprehensive Youth Ministry Zack Hinger, 513-777-4322 Ext 107 Program or Group Usual day and time: Usual day and time: Usual day and time: Usual day and time: Routine Activities Group Leader: Jr High Youth Group Events - JrHigh1x1, Movie Night, Summer Service Camp Movie Night: Tuesdays 7:00 pm – 9:00 pm, during the summer Jr. High 1x1: Monthly on Saturday afternoon/evenings & as announced, some offsite events Summer Service Camp: 1 week during the summer as announced, 8:00 am – 11:30 am Scripture Stars: Monthly as announced Comprehensive Youth Ministry for Grades 6, 7, & 8 Robin Burbrink, 513-777-4322 Ext 124 Program or Group Usual day and time Routine Activities Group Leader Mighty Max Monday - Friday as scheduled Early Childhood Ministry Charlotte Flanagan, 513-777-4322 Ext 129 Program or Group Usual day and time Routine Activities Group Leaders Religious Formation of Youth (RFY), Grades 1-8 Sunday and Monday evenings as scheduled Religious Education Classes Mary Lou Baker, 513-777-4322 Ext 120 Program or Group Usual day and time: Routine Activities: Group Leader: Sacramental Preparation for Penance and Eucharist Tuesday evenings and Saturday mornings as scheduled Formation Sessions and Retreats Carol Heuser, 513-777-4322 Ext 104 Program or Group Usual day and time: Routine Activities: Group Leader: Other Information: Sacramental Preparation for Confirmation Evenings as scheduled Formation Sessions and Retreats Robin Burbrink, 513-777-4322 Ext 124 Retreat at Jesuit Spiritual Center in Milford as detailed on separate permission slip Program or Group Usual day and time: Routine Activities: Group Leader: Teen Ensemble Wednesday evenings 7:00 pm - 9:00 pm and Sundays as announced (once a month) Monthly rehearsals and singing at Mass as announced Paula Fogt/Jennifer Shoenfelt, [email protected] Program or Group Usual day and time Routine Activities Group Leader VBS June 20-24, mornings as scheduled Comprehensive Children's and Youth Ministry Charlotte Flanagan, 513-777-4322 Ext 129 Note - Additional information may be found at the parish web site. This may include schedules, lists of specific activities, parent handbook, etc. to further inform parents(s) or guardian(s).
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