Diocese of Beaumont

Diocese of Beaumont

YOUTH REGISTRATION, CONSENT, LIABILITY WAIVER
EXHIBIT J-h
Parish/School*
Select Parish/School
Parent/Guardian Email*
example@example.com
Students Last Name*
Students Last Name
Students Name*

First NameMiddle NameLast Name
SEX of Child*

MaleFemale
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name*
Mother's Full Name
Mother's Business Address*
Mother's Business Phone*

Area CodePhone Number
Father's Name*
Father's Full Name
Father's Business Address*
Father's Phone Number*

Area CodePhone Number
Name of Relative or Neighbor Who Will Assume Temporary Care of Your Child if You Can't Be Reached*
LIST A NEIGHBOR OR RELATIVE WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD IF YOU CANNOT BE REACHED
Address*
Phone*
Additional Name of Relative or Neighbor Who Will Assume Temporary Care of Your Child if You Can't Be Reached*
LIST A NEIGHBOR OR RELATIVE WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD IF YOU CANNOT BE REACHED
Address*
Phone*
Note any health conditions such as heart disease, diabetes, eye or ear problems, epilepsy, severe allergies, chronic ailments, etc. Explanation:*
RELIGION*
CHURCH YOU ATTEND*
PLACE OF BIRTH*
City Where Child Was Born
DATE OF BIRTH*

MonthDayYear
Date
AGE*
GRADE Fall 2023*
Select Grade
I/WE THE PARENT(S) GUARDIAN(S) OF THE ABOVE NAMED INDIVIDUAL HEREBY GIVE MY/OUR CONSENT AND APPROVAL FOR HIS/HER PARTICIPATION IN ANY AND ALL ACTIVITIES SPONSORED BY THE DIOCESE OF BEAUMONT, MOST REVEREND DAVID L. TOUPS, BISHOP OF DIOCESE OF BEAUMONT, AND/OR THIS PARISH AND/OR THIS SCHOOL, AND ANY AND ALL ORGANIZERS OR SPONSORS, INCLUDING PARTICIPATION IN ATHLETIC EVENTS. I/WE ASSUME ALL RISKS AND HAZARDS INCIDENT TO THE CONDUCT OF SUCH ACTIVITIES, INCLUDING ANY AND ALL TRANSPORTATION, AND FOR AND IN CONSIDERATION OF THE EDUCATIONAL INSTRUCTION HE/SHE WILL RECEIVE IN CONNECTION THEREWITH, I/WE HEREBY AGREE TO RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS, AND DO BY THIS INSTRUMENT RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS THE DIOCESE OF BEAUMONT, MOST REVEREND DAVID L. TOUPS, BISHOP OF DIOCESE OF BEAUMONT, AND/OR THIS PARISH AND/OR THIS SCHOOL, AND ANY AND ALL ORGANIZERS OR SPONSORS, OF AND FROM ANY AND ALL LIABILITY FOR AN INJURY TO MY/OUR AFORESAID YOUTH, AND I/WE WAIVE ALL CLAIMS OF ANY KIND AGAINST ANY OR ALL OF THE ORGANIZATIONS OR PERSONS HEREINABOVE ENUMERATED, INCLUDING ANY AND ALL CLAIMS AGAINST ANY PERSONS TRANSPORTING MY/OUR CHILD TO OR FROM ANY SUCH ACTIVITIES HEREINABOVE NAMED. I WE AUTHORIZE THE PARISH AND/OR SCHOOL AND ANY AND ALL ORGANIZERS OR SPONSORS TO PERFORM A PRE-BOARDING SEARCH OF OUR SON’S/DAUGHTER’S LUGGAGE AND/OR BACKPACK AND/OR PURSE FOR ILLEGAL SUBSTANCES OR ANY ITEM WHICH MAY ENDANGER THE HEALTH OR SAFETY OF THE ORGANIZATION, ITS PARTICIPANTS OR PERSONNEL. I/WE AUTHORIZE THE PARISH AND/OR SCHOOL AND ANY AND ALL ORGANIZERS OR SPONSORS TO PERFORM A SEARCH UPON OUR SON/DAUGHTER IF HE/SHE IS SUSPECTED TO BE IN POSSESSION OF ILLEGAL SUBSTANCES OR ANY ITEM WHICH MAY ENDANGER THE HEALTH OR SAFETY OF THE ORGANIZATION, ITS PARTICIPANTS, OR PERSONNEL.
Today's Date*

MonthDayYear
Date
Father's Signature*

Clear
Mothere's Signature*

Clear
MUST BE SIGNED BY PARENTS OR GUARDIANS
I give permission for my son/daughter to attend and participate in events sponsored by this particular parish and/or this school and/or Diocese of Beaumont.
Please fill in ALL blanks below. If the answer is none or does not apply, write none or N/A in that blank. Every line needs response
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, mark 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.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Family Doctor Name*

First NameLast Name
Family Doctor's Phone Number*

Area CodePhone Number
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: My child is taking the following medication at the present time. Medication(s):*
Dosage:*
Administer:*
Permission*

I hereby Do Not Grant Permission for medication of any type, whether prescription or nonprescription may be administered by my child unless the situation is life threatening and emergency treatment is required. (Please initial)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. (Please initial)
Medical Conditions Information: Diocesan personnel will take reasonable care to see that the following information will be held in confidence.
Has had an episode of the following or has been diagnosed: Seizures Asthma Diabetic*

SeizuresAsthmaDiabeticNone
My son/daughter has:*
Allergic reactions to the following food, dyes, latex etc*
List All Allergies
Has a medically prescribed diet?*
The following physical limitations*
Date of last tetanus/diphtheria immunization*

MonthDayYear
Date
Immunizations current and up to date*

YesNo
You should also be aware of these special medical conditions of my child e.g. depression, anxiety, etc:*
Parent or Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Additional Parent or Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Insurance Company Information
Insurance Company:*
Policy Carrier (Name Employer or Individual):*
Policy Number:*
Video/Photography Consent
As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during diocesan events. 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 diocesan events.
Signature (Parent/Guardian)*

Clear
Date Signed*

MonthDayYear
Date
A PHOTOCOPY OF BOTH SIDES OF MAJOR MEDICAL INSURANCE ID CARD MUST BE ATTACHED.
If your insurance has changed since last year, take a photo of both sides of your major medical insurance card and drop them into the window below. Make sure to hit the upload button, (it will appear after dropping the files into the window).
Should be Empty:

Diocese of Beaumont

EXHIBIT J-h

MUST BE SIGNED BY PARENTS OR GUARDIANS

Medical Matters

Emergency Medical Treatment

Medications

Insurance Company Information

Video/Photography Consent