Parental Consent and Release for Powerhouse Youth Ministries

Activity or Event of Participation*

Name of Child/Youth:*

First NameLast Name

Date of Birth:*

MonthDayYear

Sex*

FemaleMale

Grade*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Youth Mobile*

Area CodePhone Number

Parish*

Name of Parent/Legal Guardian:*

First NameLast Name

Parent/Guardian Phone Number:*

Area CodePhone Number

Parent Email*

I, the parent/guardian of the above youth, grant permission to participate in this parish youth ministry event/activity. I grant permission of transportation off parish property by a legally capable adult chaperone for my child. I understand that this event/activity will take place under the leadership, responsibility, direction, and guidance of a parish employee of St. Charles Borromeo, primarily the Youth Minister, and legally capable adult volunteers.

As parent/legal guardian, I remain legally responsible for any personal actions taken by the above-named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Charles Borromeo, the Diocese of San Diego, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and the Diocese of San Diego, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of San Diego.

Signature of Parent/Legal Guardian:*

Date:*

MonthDayYear

Photo/Video Release

I, parent/legal guardian authorize the Gathering Youth Ministry, the parishes of St. Charles Borromeo and St. Agnes, the Catholic Diocese of San Diego, its representatives or volunteers, to photograph or record (audio and/or visual) the above-named minor for the sole purpose of showcasing and documenting activities and events for furthering the mission of the Gathering, the St. Charles Borromeo, and St. Agnes. I understand that any and all photos or videos will solely be used for the parish and ministry websites, social media, and other forms of ministerial publicity and will not be used for any commercial purpose whatsoever. I therefore hereby waive any kind and all rights I may have for remuneration of any kind that could otherwise accrue for the uses of such photos and/or audio or video recordings.

Signature

Date:

MonthDayYear

Medical Matters and History

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for his/her health.

Emergency Medical Treatment

In the event of an emergency, I hereby grant permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment administered by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, please contact:

Emergency Contact*

First NameLast NameRelationship to minor

Emergency Contact Phone*

Area CodePhone Number

Family Physician

First NameLast Name

Physician Phone

Area CodePhone Number

Family Healthcare Provider

Policy Number

Mild/Less Severe Medical Treatment:

In the event it comes to the attention of the parish, the Diocese of San Diego; its officers, directors, agents, volunteers, chaperones, and representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever or diarrhea, I want to be contacted.

Signature

Date:

MonthDayYear

*of the following statements pertaining to medical matters, please sign/fill only those that are applicable to your child

Medication:

My child is taking medication presently. My child will bring all medications necessary, and such medications will be well labeled. I understand it is my responsibility to notify below any and all medication my child will be bringing and taking during the course of this event/activity including the dosage amount and frequency of which medication is to be taken.

Current Medications, Dosage, and Dosage Frequency

Signature

Date:

MonthDayYear

Administration of Medication Under Mild to Severe Circumstances*

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.I hereby grant permission for nonprescription medication (aspirin, ibuprofen/advil, throat lozenges, cough syrup, etc.) to be given to my child, if deemed advisable.

Signature

Date:

MonthDayYear

Medical Information and History

The parish and ministry will take reasonable care to see that the following information is held in confidentiality.

Medical Conditions

Heart conditions, epilepsy, etc.

Allergies/Dietary Restrictions

(medications, foods, plants, etc.)

Immunization Records

Date of last tetanus/diaptheria immunization or any other vaccine

Does child have any sort of medically prescribed diet?

Does child have any sort of physical limitations?

Is child subject to chronic homesickness, emotional anxiety or distress to new environments/situations, sleepwalking, bedwetting, fainting, etc.

Has child been recently exposed to any seriously contagious illnesses, diseases, or conditions?

Mumps, measles, whooping cough, influenza, H1N1, chickenpox, COVID-19, etc.

Any other specific medical conditions about child that should be made aware

In order to make payments toward any event or activity, you will need to go to the parish website (www.saintcharlespl.com). On the home page, click on the 'Donate' tab. Select 'Youth Ministry' in the 'Fund' drop down menu. For a specific event or activity, select it in the 'Subfund' drop down menu.

Participant Registration and General Parental/Guardian Consent and Liability Waiver

Photo/Video Release

Medical Matters and History

Emergency Medical Treatment

Mild/Less Severe Medical Treatment:

Medication:

Medical Information and History