Medical, Photo and Liability Release Form

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.
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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).