I,   First Name*   Last Name* , grant permission for my child,   First Name*   Last Name*   , to participate in this parish event. This activity will take place under the guidance and direction of parish employees and / or volunteers from St. Timothy Catholic Parish

A brief description of the activity follows:
Type of Event:  Youth Ministry                  
Date of Event: September 16^th, 2023 and all subsequent Saturdays from 1:00PM-3:30PM.                         
Destination of Event:
1:00PM-2:00PM: We will meet at the big arena soccer field at Kit Carson Park (Escondido Sports Center) and play soccer for an hour.
2:00PM-2:15PM: We will walk to St. Timothy Catholic Parish from the park and say a Divine Mercy Chaplet on the way.
2:15PM-3:30PM: We will have food, games and fellowship in the parish hall. We will also discuss and learn about the Catholic faith.
Individual in Charge: Justin Mora
Estimated Time of Departure and Return: We will walk to St. Timothy Catholic Parish from Kit Carson Park (Escondido Sports Center) from 2PM to 2:15PM
Mode of Transportation to and From Event: We will walk to St. Timothy Catholic Parish from Kit Carson Park (Escondido Sports Center) from 2PM to 2:15PM
 




As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named Child. I agree on behalf of myself, my Child named herein, as well as our respective heirs, successors, and assigns, to hold harmless and defend St. Timothy Catholic Parish, and The Roman Catholic Bishop of San Diego, a corporation sole (“Diocese of San Diego”), and their respective clergy, officers, directors, employees, agents, volunteers, chaperones and representatives associated with the event, from any claim arising from or in connection with any illness or injury (including death) suffered by the above-named Child related to the above-referenced event, including the cost of medical treatment in connection therewith, and I agree to compensate the Parish, the Diocese of San Diego, and their respective clergy, officers, directors, employees, agents, volunteers, chaperones and representatives associated with the event for reasonable attorney fees and expenses which may incur in an action brought against them as a result of such injury or damage, unless such claim arises from the negligence or willful misconduct of the Parish or Diocese of San Diego.
Signature*      Date*   






MEDICAL MATTERS
I hereby warrant that 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, sign 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 will to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
First Name      
Relationship 
     Area Code   Phone Number   
Family Doctor 
      Area Code   Phone Number   
Family Health Plan Carrier   
Policy Number   

Signature   Date   

OTHER 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   
 
MEDICATIONS: My child is taking medication at present. My child will bring all medications necessary, and such medications will be well labeled. Names of medications and concise instructions for seeing that child takes such medications, including dosage and frequency of dosage is as follows:
Type Here   

    Signature   Date   

 
MEDICATIONS: CHOOSE ONE OF THE BELOW LISTINGS: (A OR B)
 
A) 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.
 
Signature   Date     
 
B)   I hereby grant permission for nonprescription medication (such as child-safe pain relievers, throat lozenges, cough syrup) to be given to my child, if deemed available.
 
    Signature   Date   

SPECIFIC MEDICAL INFORMATION
The parish will take reasonable care to see that the following information will be held in confidence.
 
Allergic reactions (medications, foods, plants, insects, etc.)   Type Here Immunizations: Date of last tetanus/diphtheria immunization   Type Here   
Does child have a medically prescribed diet?   Type Here   
 Any physical limitations?    Type Here        
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?   Type Here   
Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, H1N1, etc.? If so, date and disease or condition:   Type Here   
You should be aware of these special medical conditions of my child:Type Here   
 

PHOTO/VIDEO RELEASE

I,    First Name*    , authorize St. Timothy Catholic Parish of the Diocese of San Diego, its representatives, or volunteers, to photograph or record on audio or video (tape or digital)   First Name*   Last Name*   for purposes of furthering the mission of Youth Ministry, in this
case, the creation of publication materials for participants in Youth Ministry at Escondido Sports Center and/or St. Timothy Catholic Parish’s Parish Hall on September 16^th, 2023 and all subsequent Saturdays when Youth Group is scheduled. Photos, audio, or video may be used in printed materials and any other visual display or media. I understand that such photos and/or video recordings will be used for St. Timothy Catholic Parish related purposes 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*