Youth Medical, Permission, and Release Form

Youth Medical, Permission, and Release Form

Faith Formation 2020-2021
PERMISSION, RELEASE, AND AUTHORIZATION TO SEEK MEDICALTREATMENT FORM (rev. 7-9-2020)
1. I, the custodial parent/legal guardian of __________________________ (the“Child”),
Name of child
1.       give permission for my Child to participate in the activity described on the Activity Information Form (the “Activity”) and release from all liability, indemnify, and hold harmless St.Henry Parish (Dayton) and Our Lady of Good Hope, the Archdiocese of Cincinnati (the “Archdiocese”), the Archbishop of Cincinnati (the “Archbishop”), both individually and as trustee for the Archdiocese, all parishes and schools within the Archdiocese, and all of their agents, representatives, volunteers, and employees from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Parish and School, the Archbishop, the Archdiocese, any parish or school within the Archdiocese, or any of their agents, representatives, volunteers, or employees) incurred by my Child while participating in the Activity, traveling to or from the Activity, or while using the facilities and equipment of the Parish and School. I 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 Parish and School, the Archbishop, the Archdiocese, all parishes and schools within the Archdiocese, or their agents, representatives, volunteers, and employees.

2.       I understand that my Child’s participation in the Activity is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, agree to my Child’s participation in the Activity in spite of the risks of injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), and death. I agree that if my Child has underlying heath concerns which may place him/her at greater risk of contracting COVID-19 or that would possibly increase the severity of illness if COVID-19 is contracted, then my Child and I will consult with a health care professional before participating in the Activity.

3.       I agree to instruct my Child to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.

4.       I authorize the agents of Parish and School and/or the Archdiocese who are acting as leaders of the Activity to seek medical treatment for my Child in the event of any injury, illness, or medical emergency during the Activity or related travel. I understand that the agents of Parish and School and/or the Archdiocese will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.
5. Please indicate. I agree or I do not agree that Parish and School and/or the Archdiocese may use my Child's portrait or photograph for promotional purposes, website, and office functions*

I agreeI do not agree
6. Please indicate. I agree or I do not agree that Parish and School and/or the Archdiocese may use social media and technology to communicate with my child regarding parish/school related ministry activities.*

I agreeI do not agee
7. This Permission, Release, and Authorization 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 Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles to the contrary.

8. Parish and School, the Archdiocese, the Archbishop and their agents, employees, and volunteers shall have no liability whatsoever in the event the Activity is cancelled due, in whole or in part, to any present or future pandemic, epidemic, widespread disease or illness, public health concern, or circumstances arising therefrom, or from actions taken by any governmental or municipal authority to prevent, avoid, or mitigate the impacts thereof.

I have carefully read and understand and accept the terms and conditions stated herein and I acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment shall be effective and binding upon me, my Child, and our personal representatives, estates, assigns, heirs, and next of kin. I have signed below of my own free will.
Name of Custodian Parent/Legal Guardian *

First NameLast Name
Signature*

Clear
Today's Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Custodian Parent/ Legal Guardian's Phone Number (cell)*

Area CodePhone Number
Custodian Parent/ Legal Guardian's Phone Number (other)*

Area CodePhone Number
Place of Employment

Employer's Name

Street Address

CityState / Province

Postal / Zip Code
Name of Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Medical Information

Completed by Custodial Parent/Legal Guardian
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Allergies*
e.g. food, drugs,anesthetics
Medications Taken Regularly*
Medical Conditions or Impairements*
e.g. epilepsy, diabetes, asthma
Name of Family Doctor
Family Doctor's Phone Number

Area CodePhone Number
ACTIVITY INFORMATION FORM

Completed by Parish/School

A.        On-Going Program

Parish/School       St. Henry Parish                                                Program                Faith Formation/First Communion

Starting Date        8-1-2020 Ending Date       7-31-2021 Registration Fee $60/family. Additional Workbooks $15/each

First Communion Registration Fee __$30/student_

Usual Location     St. Henry Church, Parish Activity Center, and School. 6696 Springboro Pike, Dayton, OH 45449

Usual day and time             Sundays, vary times. Specific times can be found on the website.

Routine Activities               Mass, prayer, formation/teaching, games, crafts, food

Group Leader       Megan Deaton                                                    Telephone No.    937-434-923

Email     mdeaton@sthenryparish.com

__X___ Check here if any additional information is attached. (Note: any additional activity information (e.g. schedule, list of specific activities, etc.) may be attached to further inform parents(s) or guardian(s). Calendar can be found online at www.sthenryparish.com/faith-formation
Signature of Custodian Parent/Legal Guardian that completed the medical information*

Clear
Should be Empty:

Youth Medical, Permission, and Release Form

PERMISSION, RELEASE, AND AUTHORIZATION TO SEEK MEDICALTREATMENT FORM (rev. 7-9-2020)

Medical Information