Awakening March 19, 2023

Awakening - March 19, 2023

St. Basil Youth Program for 6-8th Graders - St. Basil Family Life Center 6:30-8:15pm.
An evening to encounter Jesus through high energy games, powerful messages, skits, small group discussions, and praise and worship presented by a team of extremely talented, highly trained missionary disciples from Damascus Catholic Mission Campus - the home of Catholic Youth Summer Camp.
Parent Name*
Parent Email*
Are you or another parent able to help out this time (with small things like serving food, assisting w/ check-in, etc.)?

YesNo
How many students are you RSVPing for?

1234
Student 1 Full Name*
Student 1 Grade*

6th grade7th8th
Have you filled out an Emergency Medical form for Student 1 because you completed them last month or they are currently enrolled in St. Basil PSR?*

Yes, I've filled out an Emergency Medical forms already this year.No
Emergency Medical Authorization Form for Student 1

St. Basil Parish School of Religion
Student 1's Full Name
Student 1 Age
Student 1 Gender

MaleFemale
Student 1 Grade
Student 1 Parent/Guardian Names
Student 1 Birthdate
Student 1 Parent Cell phone
Student 1 Home Address
Student 1's Doctor Name
Student 1's Doctor's phone
Student 1 Dentist Name
Student 1 Dentist phone
Student 1 Hospital of Choice
Student 1 Hospital of Choice phone
Student 1 Insurance Provider
Student 1 Insurance Provider phone
Please list any medical issues or concerns for Student 1
Please list allergies or sensitivities Student 1 might have to any food, drink, or materials that might be used at St. Basil
Please list any medical allergies for Student 1
Are there any activities in which Student 1 may NOT participate?
Student 1 Emergency Contact #1 Name
Student 1 Emergency Contact #1 Phone
Student 1 Emergency Contact #1 Relationship to Child
Student 1 Emergency Contact #2 Name
Student 1 Emergency Contact #2 Phone
Student 1 Emergency Contact #2 Relationship to Child
Grant of Consent

Sign directly below if you wish to grant consent
1.        I understand what is involved in the Activity and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Activity. I recognize the possibility and risk of injury associated with my child’s participation in the Activity and that such injury can include, but is not limited to, pain, suffering, serious bodily injury, psychological injury, temporary or permanent disability, temporary or permanent paralysis, illness, disfigurement, further injury by medical treatment, and/or death. I understand that such injuries can occur for any number of reasons which are both foreseeable and unforeseeable and which include, but are not limited to, my child’s own actions or inaction, the actions or inaction of others (whether negligent, intentional, or otherwise), and equipment failure.

2.         I further 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. I and my spouse assume, for ourselves and on behalf of our minor child, all risks in connection with my child’s participation in the Activity.

3.         I agree to instruct my child to cooperate with those persons in charge of the activity. I understand and agree that, in the event my child does not cooperate with the person(s) in charge of the activity, which shall be determined at the sole discretion of the person(s) in charge of the activity, I agree to cooperate with the Parish in picking up my child to remove them from the activity.

4.         To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, as well as our respective heirs and assigns, executors, all other legal representatives and any others claiming through us or on behalf of us, hereby agree to release, discharge, hold harmless and indemnify the Parish, the Catholic Diocese of Cleveland, the Bishop or Administrator of the Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers (“Released Parties”) forever from and against any and all claims, lawsuits, damages, judgments, expenses including attorney’s fees, liabilities (of any nature or extent), demands, damages, cause of action of any nature and kind, known or unknown, which in any way arise out of or relate to my child’s participation in the Activity (including without limitation any injury, loss, or damage to my child’s person or property), whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person) (the “Claims”).

5.         I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.

6.         In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.
Signature for Consent

Clear
Date

MonthDayYear
Date
REFUSAL of Consent

Only sign below if you refuse consent and did not sign above, granting consent.
I do not give my consent for emergency medical treatment of my child.
In the event of illness or emergency treatment being required, I wish the school authorities to take no action or to:
Date

MonthDayYear
Date
Signature for Refusal

Clear
PHOTO RELEASE
I consent and grant permission for the Parish and/or its agents to record (in writing or otherwise), photograph, audio record, and video record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to display, release, exhibit, publish, or distribute the Recordings, or any part thereof, for the purpose of and in connection with any material that may be created by or on behalf of the Parish including, without limitation, through the Parish’s bulletin boards, social media, website, print and electronic media, marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation, and I agree that the Recordings shall constitute the sole property of the Parish. I further agree to release the Parish, the Catholic Diocese of Cleveland, and the Bishop of the Diocese of Cleveland, and their respective officers, directors, agents, employees and/or attorneys from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officer, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release.
Photo Release Signature

Clear
Date

MonthDayYear
Date
Student 2 Full Name
Student 2 Grade

6th grade7th8th
Have you filled out Emergency Medical forms for Student 2, either because they are enrolled in St. Basil PSR or because you filled them out through a previous month's Awakening RSVP?

Yes, I've filled out those forms already.No
Emergency Medical Authorization Form for Student 2

St. Basil Parish School of Religion
Student 2's Full Name
Student 2 Age
Student 2 Gender

MaleFemale
Student 2 Grade
Student 2 Parent/Guardian Names
Student 2 Birthdate
Student 2 Parent Cell phone
Student 2 Home Address
Student 2's Doctor Name
Student 2's Doctor's phone
Student 2 Dentist Name
Student 2 Dentist phone
Student 2 Hospital of Choice
Student 2 Hospital of Choice phone
Student 2 Insurance Provider
Student 2 Insurance Provider phone
Please list any medical issues or concerns for Student 2
Please list allergies or sensitivities Student 2 might have to any food, drink, or materials that might be used at St. Basil
Please list any medical allergies for Student 2
Are there any activities in which Student 2 may NOT participate?
Student 2 Emergency Contact #1 Name
Student 2 Emergency Contact #1 Phone
Student 2 Emergency Contact #1 Relationship to Child
Student 2 Emergency Contact #2 Name
Student 2 Emergency Contact #2 Phone
Student 2 Emergency Contact #2 Relationship to Child
Grant of Consent

Sign directly below if you wish to grant consent
1.        I understand what is involved in the Activity and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Activity. I recognize the possibility and risk of injury associated with my child’s participation in the Activity and that such injury can include, but is not limited to, pain, suffering, serious bodily injury, psychological injury, temporary or permanent disability, temporary or permanent paralysis, illness, disfigurement, further injury by medical treatment, and/or death. I understand that such injuries can occur for any number of reasons which are both foreseeable and unforeseeable and which include, but are not limited to, my child’s own actions or inaction, the actions or inaction of others (whether negligent, intentional, or otherwise), and equipment failure.

2.         I further 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. I and my spouse assume, for ourselves and on behalf of our minor child, all risks in connection with my child’s participation in the Activity.

3.         I agree to instruct my child to cooperate with those persons in charge of the activity. I understand and agree that, in the event my child does not cooperate with the person(s) in charge of the activity, which shall be determined at the sole discretion of the person(s) in charge of the activity, I agree to cooperate with the Parish in picking up my child to remove them from the activity.

4.         To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, as well as our respective heirs and assigns, executors, all other legal representatives and any others claiming through us or on behalf of us, hereby agree to release, discharge, hold harmless and indemnify the Parish, the Catholic Diocese of Cleveland, the Bishop or Administrator of the Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers (“Released Parties”) forever from and against any and all claims, lawsuits, damages, judgments, expenses including attorney’s fees, liabilities (of any nature or extent), demands, damages, cause of action of any nature and kind, known or unknown, which in any way arise out of or relate to my child’s participation in the Activity (including without limitation any injury, loss, or damage to my child’s person or property), whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person) (the “Claims”).

5.         I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.

6.         In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.
Signature for Consent

Clear
Date

MonthDayYear
Date
REFUSAL of Consent

Only sign below if you refuse consent and did not sign above, granting consent.
I do not give my consent for emergency medical treatment of my child.
In the event of illness or emergency treatment being required, I wish the school authorities to take no action or to:
Date

MonthDayYear
Date
Signature for Refusal

Clear
PHOTO RELEASE
I consent and grant permission for the Parish and/or its agents to record (in writing or otherwise), photograph, audio record, and video record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to display, release, exhibit, publish, or distribute the Recordings, or any part thereof, for the purpose of and in
connection with any material that may be created by or on behalf of the Parish including, without limitation, through the Parish’s bulletin boards, social media, website, print and electronic media, marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation, and I agree that the Recordings shall constitute the sole property of the Parish. I further agree to release the Parish, the Catholic Diocese of Cleveland, and the Bishop of the Diocese of Cleveland, and their respective officers, directors, agents, employees and/or attorneys from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officer, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release.
Photo Release Signature

Clear
Date

MonthDayYear
Date
Student 3 Full Name
Student 3 Grade

6th grade7th8th
Have you filled out Emergency Medical forms for Student 3, either because they are enrolled in St. Basil PSR or because you filled them out through a previous month's Awakening RSVP?

Yes, I've filled out those forms already.No
Emergency Medical Authorization Form for Student 3

St. Basil Parish School of Religion
Student 3's Full Name
Student 3 Age
Student 3 Gender

MaleFemale
Student 3 Grade
Student 3 Parent/Guardian Names
Student 3 Birthdate
Student 3 Parent Cell phone
Student 3 Home Address
Student 3's Doctor Name
Student 3's Doctor's phone
Student 3 Dentist Name
Student 3 Dentist phone
Student 3 Hospital of Choice
Student 3 Hospital of Choice phone
Student 3 Insurance Provider
Student 3 Insurance Provider phone
Please list any medical issues or concerns for Student 3
Please list allergies or sensitivities Student 3 might have to any food, drink, or materials that might be used at St. Basil
Please list any medical allergies for Student 3
Are there any activities in which Student 3 may NOT participate?
Student 3 Emergency Contact #1 Name
Student 3 Emergency Contact #1 Phone
Student 3 Emergency Contact #1 Relationship to Child
Student 3 Emergency Contact #2 Name
Student 3 Emergency Contact #2 Phone
Student 3 Emergency Contact #2 Relationship to Child
Grant of Consent

Sign directly below if you wish to grant consent
1.        I understand what is involved in the Activity and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Activity. I recognize the possibility and risk of injury associated with my child’s participation in the Activity and that such injury can include, but is not limited to, pain, suffering, serious bodily injury, psychological injury, temporary or permanent disability, temporary or permanent paralysis, illness, disfigurement, further injury by medical treatment, and/or death. I understand that such injuries can occur for any number of reasons which are both foreseeable and unforeseeable and which include, but are not limited to, my child’s own actions or inaction, the actions or inaction of others (whether negligent, intentional, or otherwise), and equipment failure.

2.         I further 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. I and my spouse assume, for ourselves and on behalf of our minor child, all risks in connection with my child’s participation in the Activity.

3.         I agree to instruct my child to cooperate with those persons in charge of the activity. I understand and agree that, in the event my child does not cooperate with the person(s) in charge of the activity, which shall be determined at the sole discretion of the person(s) in charge of the activity, I agree to cooperate with the Parish in picking up my child to remove them from the activity.

4.         To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, as well as our respective heirs and assigns, executors, all other legal representatives and any others claiming through us or on behalf of us, hereby agree to release, discharge, hold harmless and indemnify the Parish, the Catholic Diocese of Cleveland, the Bishop or Administrator of the Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers (“Released Parties”) forever from and against any and all claims, lawsuits, damages, judgments, expenses including attorney’s fees, liabilities (of any nature or extent), demands, damages, cause of action of any nature and kind, known or unknown, which in any way arise out of or relate to my child’s participation in the Activity (including without limitation any injury, loss, or damage to my child’s person or property), whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person) (the “Claims”).

5.         I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.

6.         In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.
Signature for Consent

Clear
Date

MonthDayYear
Date
REFUSAL of Consent

Only sign below if you refuse consent and did not sign above, granting consent.
I do not give my consent for emergency medical treatment of my child.
In the event of illness or emergency treatment being required, I wish the school authorities to take no action or to:
Date

MonthDayYear
Date
Signature for Refusal

Clear
PHOTO RELEASE
I consent and grant permission for the Parish and/or its agents to record (in writing or otherwise), photograph, audio record, and video record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to display, release, exhibit, publish, or distribute the Recordings, or any part thereof, for the purpose of and in
connection with any material that may be created by or on behalf of the Parish including, without limitation, through the Parish’s bulletin boards, social media, website, print and electronic media, marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation, and I agree that the Recordings shall constitute the sole property of the Parish. I further agree to release the Parish, the Catholic Diocese of Cleveland, and the Bishop of the Diocese of Cleveland, and their respective officers, directors, agents, employees and/or attorneys from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officer, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release.
Photo Release Signature

Clear
Date

MonthDayYear
Date
Student 4 Full Name
Student 4 Grade

6th grade7th8th
Have you filled out Emergency Medical forms for Student 4, either because they are enrolled in St. Basil PSR or because you filled them out through a previous month's Awakening RSVP?

Yes, I've filled out those forms already.No
Emergency Medical Authorization Form for Student 4

St. Basil Parish School of Religion
Student 4's Full Name
Student 4 Age
Student 4 Gender

MaleFemale
Student 4 Grade
Student 4 Parent/Guardian Names
Student 4 Birthdate
Student 4 Parent Cell phone
Student 4 Home Address
Student 4's Doctor Name
Student 4's Doctor's phone
Student 4 Dentist Name
Student 4 Dentist phone
Student 4 Hospital of Choice
Student 4 Hospital of Choice phone
Student 4 Insurance Provider
Student 4 Insurance Provider phone
Please list any medical issues or concerns for Student 4
Please list allergies or sensitivities Student 4 might have to any food, drink, or materials that might be used at St. Basil
Please list any medical allergies for Student 4
Are there any activities in which Student 4 may NOT participate?
Student 4 Emergency Contact #1 Name
Student 4 Emergency Contact #1 Phone
Student 4 Emergency Contact #1 Relationship to Child
Student 4 Emergency Contact #2 Name
Student 4 Emergency Contact #2 Phone
Student 4 Emergency Contact #2 Relationship to Child
Grant of Consent

Sign directly below if you wish to grant consent
1.        I understand what is involved in the Activity and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Activity. I recognize the possibility and risk of injury associated with my child’s participation in the Activity and that such injury can include, but is not limited to, pain, suffering, serious bodily injury, psychological injury, temporary or permanent disability, temporary or permanent paralysis, illness, disfigurement, further injury by medical treatment, and/or death. I understand that such injuries can occur for any number of reasons which are both foreseeable and unforeseeable and which include, but are not limited to, my child’s own actions or inaction, the actions or inaction of others (whether negligent, intentional, or otherwise), and equipment failure.

2.         I further 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. I and my spouse assume, for ourselves and on behalf of our minor child, all risks in connection with my child’s participation in the Activity.

3.         I agree to instruct my child to cooperate with those persons in charge of the activity. I understand and agree that, in the event my child does not cooperate with the person(s) in charge of the activity, which shall be determined at the sole discretion of the person(s) in charge of the activity, I agree to cooperate with the Parish in picking up my child to remove them from the activity.

4.         To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, as well as our respective heirs and assigns, executors, all other legal representatives and any others claiming through us or on behalf of us, hereby agree to release, discharge, hold harmless and indemnify the Parish, the Catholic Diocese of Cleveland, the Bishop or Administrator of the Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers (“Released Parties”) forever from and against any and all claims, lawsuits, damages, judgments, expenses including attorney’s fees, liabilities (of any nature or extent), demands, damages, cause of action of any nature and kind, known or unknown, which in any way arise out of or relate to my child’s participation in the Activity (including without limitation any injury, loss, or damage to my child’s person or property), whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person) (the “Claims”).

5.         I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.

6.         In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.
Signature for Consent

Clear
Date

MonthDayYear
Date
REFUSAL of Consent

Only sign below if you refuse consent and did not sign above, granting consent.
I do not give my consent for emergency medical treatment of my child.
In the event of illness or emergency treatment being required, I wish the school authorities to take no action or to:
Signature for Refusal

Clear
Date

MonthDayYear
Date
PHOTO RELEASE
I consent and grant permission for the Parish and/or its agents to record (in writing or otherwise), photograph, audio record, and video record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to display, release, exhibit, publish, or distribute the Recordings, or any part thereof, for the purpose of and in connection with any material that may be created by or on behalf of the Parish including, without limitation, through the Parish’s bulletin boards, social media, website, print and electronic media, marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation, and I agree that the Recordings shall constitute the sole property of the Parish. I further agree to release the Parish, the Catholic Diocese of Cleveland, and the Bishop of the Diocese of Cleveland, and their respective officers, directors, agents, employees and/or attorneys from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officer, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release.
Photo Release Signature

Clear
Date

MonthDayYear
Date
*Please note that we will need an RSVP monthly for Awakening. If we already have your medical forms on file from PSR or from this form, then you won't have to fill those out again. For future Awakenings, RSVP's will require a few fields of information for food and supply counts. Thanks!
Please review your form to ensure you have filled out all the necessary fields.*

I have filled out all the information.
Should be Empty:

Awakening - March 19, 2023

Emergency Medical Authorization Form for Student 1

Grant of Consent

REFUSAL of Consent

PHOTO RELEASE

Emergency Medical Authorization Form for Student 2

Grant of Consent

REFUSAL of Consent

PHOTO RELEASE

Emergency Medical Authorization Form for Student 3

Grant of Consent

REFUSAL of Consent

PHOTO RELEASE

Emergency Medical Authorization Form for Student 4

Grant of Consent

REFUSAL of Consent

PHOTO RELEASE