High School Andretti Permission, Release, and Liability Waiver

ACTIVITY: Teen ACTS Retreat (2021-22 - 9th-12th graders)

DATE: Retreat is August 4-7, 2022

DESTINATION: Sanctus Ranch 2647 River Bluff Circle, Pipe Creek, TX 78063

Drop off Time: 6:00 PM meet at OLG

MODE of TRANSPORTATION: Bus and/or approved volunteer drivers

Pick up Time: 1:30 pm from OLG

Designated Supervisor of Activity: Angla Quintanilla

Parish/School/Organization (“Sponsor”): Guadalupe Youth Ministry

Participant's First Name *

Participant's Last Name *

Date of Birth *

Date

Grade Level for 2021-22 school year

Adult T-shirt Size

Communication Consent with a Minor. The following statements provide your legal consent to Our Lady of Guadalupe Catholic Church - Youth Ministries regarding communication with your minor child(ren) These statements are important to protect the child, the parent/guardian/conservator, volunteers, pastor and staff of Our Lady of Guadalupe Catholic Church. *

I grant permission to Our Lady of Guadalupe Catholic Church- Youth Ministries to communicate with my child(ren) through the GROUPME app. This communication system will provide updates for youth events and relative information for youth in the parish and keeps a record of all communication. Parents will be copied on emails and text messages. I do not grant permission to Our Lady of Guadalupe Catholic Church- Youth Ministries to communicate with my child(ren) through the GROUPME app.

Initials *

Participant's Email

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Participant's Cell Phone Number

Please enter a valid phone number.

Please list any food or environmental allergies *

If there are no known allergies, please type "none"

Does the participant take prescribed medication? *

List name of medication, reason for medication, dosage as prescribed and times to be administered *

Do you give us permission to administer over the counter medication such as pain relievers like acetaminophen (Tylenol) and ibuprofen (Advil, Motrin), cough suppressants such as dextromethorphan (Robitussin) and antihistamines like loratadine (Claritin 24H), tums, etc.? *

Parent/Guardian's Name *

Parent/Guardian's Cell Phone *

Please enter a valid phone number.

Parent Email *

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Second Parent/Guardian/Emergency contact Name *

Second parent/guardian/emergency contact Cell Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

In consideration for Participant, a minor child, being permitted by Sponsor to participate in the Activity, which includes transportation to, from, and during the Activity (the “Transportation”), I, being the undersigned and the parent/legal guardian of Participant, hereby acknowledge, consent, and agree as follows:

1. Consent to Participate and to Transportation. I hereby consent to Participant’s participation in the Activity. I further consent to the Transportation of Participant by means of the method of transportation designated above.

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2. Knowledge of Risks. I acknowledge and agree that I have been advised by Sponsor and that I understand that participation by Participant in the Activity and the Transportation of Participant may involve serious risks, including, without limitation, death, bodily injury, damage to personal property, and dangers resulting from injury or accident. Knowing the risks, dangers, and hazards involved in Participant’s participation in the Activity and Transportation, I nevertheless voluntarily consent and agree to Participant’s participation in the Activity and Transportation.

I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, HEREBY EXPRESSLY AND SPECIFICALLY ASSUME FULL RESPONSIBILITY FOR ANY AND ALL RISKS OF DEATH OR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT’S PERSONAL PROPERTY RESULTING FROM OR ARISING OUT OF (I) PARTICIPANT’S PARTICIPATION IN THE ACTIVITY, OR (II) SPONSOR’S TRANSPORTATION OF PARTICIPANT, WHETHER CAUSED BY OR CONTRIBUTED BY THE NEGLIGENCE OF THE SPONSOR, THE ARCHDIOCESE OF SAN ANTONIO (THE “ARCHDIOCESE”), OR ANY OF THEIR RESPECTIVE AFFILIATES, DIRECTORS, OFFICERS, AGENTS, EMPLOYEES, VOLUNTEERS, SUCCESSORS AND ASSIGNS (COLLECTIVELY, THE “CHURCH PARTIES”) OR OTHERWISE.

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3. RELEASE AND WAIVER. I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, HEREBY, RELEASE, WAIVE, AND FOREVER DISCHARGE THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS, LOSSES, JUDGMENTS, DAMAGES, COSTS, EXPENSES, AND DEMANDS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, RESULTING OR ARISING FROM PARTICIPANT’S PARTICIPATION IN THE ACTIVITY OR SPONSOR’S TRANSPORTATION OF PARTICIPANT. I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, HEREBY EXPRESSLY ACKNOWLEDGE AND AGREE THAT (I) THIS RELEASE DISCHARGES ALL OF THE CHURCH PARTIES FROM ANY AND ALL LIABILITY THAT PARTICIPANT AND I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, MAY HAVE AGAINST THE CHURCH PARTIES WITH RESPECT TO THE DEATH OR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT’S PERSONAL PROPERTY THAT MAY RESULT FROM (I) PARTICIPANT’S PARTICIPATION IN THE ACTIVITY, OR (II) SPONSOR’S TRANSPORTATION OF PARTICIPANT; AND (III) THIS RELEASE EXTENDS TO ALL ACTS OF NEGLIGENCE, WHETHER CAUSED BY OR CONTRIBUTED BY ANY OF THE CHURCH PARTIES OR OTHERWISE.

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4. INDEMNITY. I, INDIVIDUALLY AND IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT, UNCONDITIONALLY AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS, LOSSES, JUDGMENTS, DAMAGES, DEMANDS, COSTS AND EXPENSES OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, (INCLUDING, WITHOUT LMITATION, COURT COSTS AND ATTORNEY’S FEES) INCURRED BY ANY OF THE CHURCH PARTIES RESULTING OR ARISING FROM (I) PARTICIPANT’S PARTICIPATION IN THE ACTIVITY, OR (II) SPONSOR’S TRANSPORTATION OF PARTICIPANT, INCLUDING, WITHOUT LIMITATION, THE DEATH OR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT’S PERSONAL PROPERTY THAT MAY RESULT FROM (I) PARTICIPANT’S PARTICIPATION IN THE ACTIVITY, OR (II) SPONSOR’S TRANSPORTATION OF PARTICIPANT, WHETHER CAUSED BY OR CONTRIBUTED BY THE NEGLIGENCE OF ANY OF THE CHURCH PARTIES OR OTHERWISE.

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5. Medical Authorization. In the event of any injury or illness of Participant during the Activity, I hereby authorize and consent to the transportation of Participant to the nearest medical or dental facility, and, should the need arise, I hereby further authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis and treatment in the discretion of the attending physician or dentist. I understand that I am giving this authorization in advance of any specific diagnosis, treatment or hospital care being required and I am providing this authorization to give authority and power to render any care which the medical provider and/or dental provider deems advisable. None of the foregoing medical or dental treatments shall be withheld if I cannot be reached prior to the administration of such medical and/or dental treatments. I hereby agree that I shall be solely responsible for the payment of any and all costs for such medical and/or dental treatment of Participant, and in no event shall any of the Church Parties be required to pay for any such costs or expenses.

I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, HEREBY, RELEASE, WAIVE, AND FOREVER DISCHARGE THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS, LOSSES, JUDGMENTS, DAMAGES, COSTS, EXPENSES, AND DEMANDS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, RESULTING OR ARISING FROM ANY SUCH MEDICAL OR DENTAL TREATMENT RENDERED TO PARTICIPANT.

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6. Photo/Video Consent and Release. I hereby authorize Sponsor and the Archdiocese to take photographs, recordings, and/or videos (whether electronic, digital, or otherwise) of Participant in connection with the Activity, and I hereby consent to the use, reproduction, and publication of such images by Sponsor and the Archdiocese in connection with the promotion and publicity of the activities of Sponsor and the Archdiocese, including, without limitation, publication of such images on Sponsor’s website. I, individually and in my capacity as parent/legal guardian of Participant, hereby waive any right to inspect or approve the actual use by Sponsor or the Archdiocese of any such image of Participant. Such images of Participant shall be the sole property of Sponsor, and I, individually and in my capacity as parent/legal guardian of Participant, acknowledge and agree that neither I nor Participant shall be entitled to any compensation whatsoever should any such images of Participant be used by Sponsor or the Archdiocese.

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7. COVENANT NOT TO SUE. I HEREBY ACKNOWLEDGE AND AGREE THAT I, INDIVIDUALLY OR IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT, WILL NOT INSTITUTE ANY SUIT OR ACTION AT LAW, OR OTHERWISE, AGAINST ANY OF THE CHURCH PARTIES OR INITIATE OR ASSIST IN THE PROSECUTION OF ANY CLAIM FOR DAMAGES, OR CAUSES OF ACTION, WHICH I, INDIVIDUALLY AND/OR IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT, MAY HAVE BY REASON OF INJURY OR DEATH TO PARTICIPANT OR DAMAGE TO PARTICIPANT’S PERSONAL PROPERTY RESULTING OR ARISING FROM PARTICIPANT’S PARTICIPATION IN THE ACTIVITY OR SPONSOR’S TRANSPORTATION OF PARTCIPANT.

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8. Severability. If any term, covenant, or condition of this Parental/Guardian Permission, Release, and Waiver of Liability (the “Agreement”) is, to any extent, invalid, illegal, or unenforceable, I hereby agree that the remainder of this Agreement shall not be affected thereby, and shall, notwithstanding, remain binding, valid and enforceable to the fullest extent permitted by law.

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I COVENANT, CERTIFY AND REPRESENT TO SPONSOR THAT I AM THE PARENT/LEGAL GUARDIAN OF PARTICIPANT AND THAT I HAVE FULL LEGAL AUTHORITY TO ENTER INTO THIS AGREEMENT ON BEHALF OF PARTICIPANT. I HAVE (I) FULLY READ THIS AGREEMENT, (II) FULLY UNDERSTAND ITS TERMS, AND (III) AGREE TO BE BOUND BY ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. I UNDERSTAND THAT I, ON MY OWN BEHALF AND ON BEHALF OF PARTICIPANT, HAVE GIVEN UP SUBSTANTIAL LEGAL RIGHTS BY SIGNING THIS AGREEMENT. I, INDIVIDUALLY AND IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT, SIGNED THIS AGREEMENT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME BY ANY OF THE CHURCH PARTIES. I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE BY ME AND PARTICIPANT OF ALL LIABILITY AGAINST THE CHURCH PARTIES TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW.

Signature of Participant's Parent/Legal Guardian *

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Printed Name of Participant's Parent/Legal Guardian *

Date *

Date

Name of Health Insurance and Group # and/or ID # *

Photocopy of FRONT of Health Insurance Card Upload *

Photocopy of BACK of Health Insurance Card Upload *

Last 4 digits of the Credit Card Being Used *

Fee $125 *

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Teen ACTS Retreat 2022 WAIVER

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