Archdiocese of Dubuque
2023-2024 Annual Parental/Guardian Consent Form and Liability Waiver
Valid date signed through 8-31-24

This Consent Form and Liability Waiver is required for and serves both on-site programs and off- site/field trip events/activities for the stated program year. This form needs to be completed annuallyfor each student. To obtain the needed permission, contact, emergency and medical information you are requested to supply the needed information. As the specifics of each off-site/field trip event are known you will be required to complete an Off-site/Field Trip Permission Form outlining the specifics of each activity. Please complete all sections.

Section 1 - Contact Information

Section 2 - Off-site/Field Trip Consent Form and Liability Waiver , (Parent or Guardian's Name) grant permission (Name of Child) to participate in school/parish events this year that may require transportation to a location away from the school/parish site. The activities will take place under the guidance and direction of school/parish employees and/or volunteers of

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (" Participant" I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend, its officers, directors of (Name of School/Parish) and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events, arising from or in connection with my child attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events for reasonable attorney's fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Archdiocese of Dubuque.

Section 3 - Specific 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. Item A - 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 wish 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:

Item B - Other Medical Treatment: In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I want to be notified. Yes

If Yes, Please call: On-site Nonprescription Medication Permission - I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc to be given to my child in the event a condition arises after my child is already in attendance at the on site program. Yes

Item C - Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence. Check/explain all that are applicable to this student/participant. Allergic reactions (medications, foods, plants, insects, etc:

You should be aware of these special medical conditions of my child:

THIS FORM REPLACES PREVIOUS VERSIONS AS OF DATE SIGNED

Administration of Medication - Archdiocesan Catholic School Board Policy 5141, items 9-10. (For Catholic School programs only) 9. Dispensing of prescription medication 1. For Catholic schools - Dispensing of prescription medication will be administered by a nurse or designated party with training and with the written consent of parent(s)/guardian(s Prescription medication must be provided to the school in the original labeled container containing the physician's name, name of the medication, and dosage/frequency to be given. A record of each dose of medication administered will be documented in the pupil's health record. 2. Students utilizing asthma or airway constricting prescription medication are allowed to administer their own dosage provided a completed consent form is on file in the school/program office. Such forms must be filed annually. 3. Contraceptives will not be dispensed. Iowa Code $280.16 10. Dispensing of nonprescription medication may occur, provided the parent/guardian have signed and dated an authorization identifying medication, dosage, and time interval to be administered. Nonprescription medications can be provided on off-site field trips if the parent/guardian signs a nonprescription medication authorization for each off-site field trip.