ECYM Youth Ministry Forms 2023-2024

Eastside Catholic Youth Ministries (2023-2024)

These forms will be kept on file for your student. Please fill out an individual set of forms for each child in your household (grades 5-12)
Eastside Catholic Youth Ministries Youth Events Release Form

1. I, the custodial parent/legal guardian of:
Child Name (First and Last)*
(the “Child”), give permission for my Child to participate in the activity described under Activity Information (the “Activity”) and release from all liability, indemnify, and hold harmless S-3 FAMILY OF PARISHES (“Parish and School”), 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:*
that Parish and School and/or the Archdiocese may use my Child’s portrait or photograph for promotional purposes, website, and office functions.
6. Please indicate:*
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.
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.

9. S-3 Family of Parishes will retain both this release and the contact/medical form on file for the school year, and any off-site, overnight, or other event outside the scope of this release will require an additional release.

Activity Information: On-Going Program

Church Agency:S-3 FAMILY OF PARISHES Program: MIDDLE SCHOOL (5TH-8TH GRADE)/HIGH SCHOOL (9TH-12TH GRADE) YOUTH MINISTRY Starting Date: 07/01/23 Ending Date: 06/30/24 Registration Fee: NONE Usual Location: ST.JOHN FISHER (3227 CHURCH STREET, CINCINNATI, OH 45244), GA (6531 BEECHMONT AVENUE, CINCINNATI, OH 45230), IHM (7820 BEECHMONT AVENUE, CINCINNATI, OH 45255) Usual Day/Time: TUESDAYS (MIDDLE SCHOOL, 6:30-8:00 PM), THURSDAYS (HIGH SCHOOL, 7:00-9:00 PM), OTHER ACTIVITIES AS DETAILED IN HANDBOOK AND WEBSITE CALENDAR Routine Activities: SPEAKERS, RECREATIONAL ACTIVITIES, WORSHIP, PRAYER, GAMES Group Leader: BRADLEY BARNES Contact Number: 513-624-3148
I recognize that it is my family’s responsibility to review program information contained in the Youth Ministry Handbook. 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.
Parent/Guardian Name (First and Last):*
Signature of Parent/Guardian:*

Clear
Date*

MonthDayYear
Date

2023-2024 Contact & Medical Information (Completed by Parent/Guardian)
Home Street Address*
City*
State*
Zip Code*
Parent Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number (will be added to receive text notifications)
Please enter a valid phone number.
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Child Email
example@example.com
Child School (2023-2024)*
Child Grade (2023-2024)*
Home Church*
All faith backgrounds welcome. If you do not have a church home, please put N/A.
Child Birthdate*

MonthDayYear
Date
Child Social Security Number*
* Social Security Number is optional - please note that some hospitals will not treat without it.
Child Allergies
Child Medications
Upon review of the Youth Ministry Handbook (page 12), permission is granted to administer the listed Over the Counter Medications to this student, adhering to package instructions and dosage. Meds are administered by adults only, and we will exclude any that are listed under allergies. Please indicate below:
If there are any medications from the list that you would not like this student to receive, please list below:
i.e. No Benadry, no Ibuprofen, etc.
OTC Meds (as listed) may be given to this student*
Child Chronic Conditions
e.g. Epilepsy, Diabetes
Medical Insurance Company*
Medical Insurance Policy Number*
Member Name*

First NameLast Name
Member Home Phone*
Please enter a valid phone number.
Member Work Phone
Please enter a valid phone number.
Member Birthdate*

MonthDayYear
Date
Member Social Security Number*
* Social Security Number is optional - please note that some hospitals will not treat without it.
Family Doctor
Doctor Phone Number
Please enter a valid phone number.
I acknowledge that this information is correct for the school year, and hereby give my consent to Eastside Catholic Youth Ministries to dispense the medication(s) listed above to my child as needed. I also understand that prescription (or otherwise unlisted) medication for overnight/longer events will need to be logged on a separate sheet (distributed for each event).
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Eastside Catholic Youth Ministries (2023-2024)