Form A: Annual Youth Ministry Parental Liability Waiver, Permission and Medical Information

Catholic Diocese of Fort Worth and/or the Parish of*

Youth Participant's Name*

Birth Date (MM/DD/YYYY)*

Sex*

MaleFemale

Parent/Guardian Name*

Home Address*

(Please enter Street Address, City, State, Zip Code)

Cell Phone*

Texting*

YesNo

E-mail of Parent*

Email of Youth Minister / DRE from your Parish*

(This email ensures your Youth Minister is sent a copy of this form. Please enter the correct email address.)

Emergency Contact Name (other than parent/guardian)*

Relationship to the Youth Participant*

Primary Phone Number*

Texting*

YesNo

INSURANCE INFORMATION

Is the participant insured?*

YesNo

Name of Policy Holder (whose name is the policy in)*

Insurance Carrier/Name of Insurance Co*

Policy Number*

Insurance ID Number*

Claim Address*

(Please enter Street Address, City, State, Zip Code)

Customer Service Phone Number*

MEDICAL INFORMATION

Prescriptions and Medications:*

This child takes no medication and will bring no medication with him/her.This child takes medication but is unable to self-medicate. The child’s parent/guardian/conservator will provide and dispense any and all needed medications.This child takes medication(s) and will self-medicate. The child will bring all such medications necessary, and such medications will be clearly labeled. I understand that the child will be required to turn all medication(s) over to a supervising adult designated to keep medication(s). I further understand that it will be this child’s responsibility to present himself/herself at a location designated for returning medication(s) to this child at the frequencies/times listed below. I understand that the adult to whom this child surrenders the medication has no medical training and this adult will not measure dosages. This child will return the medication(s) to the adult after he/she self-medicates. At the conclusion of the event it will be this child’s responsibility to pick up remaining medication(s), if any, at the self-medication designated location. Names of medications and exact dosage and frequencies/times are as listed below: (you may attach a sheet to this form if you need more space just make sure to sign and date it as well).

Names of medications and exact dosage and frequencies/times

Over-The-Counter Medication Permission:*

No medication of any type whether prescription or nonprescription may be administered to this child unless the situation is life-threatening and emergency treatment is required.I grant permission for the following nonprescription medication to be given to this child in the recommended dosage on the medication bottle.

Non-aspirin pain reliever: *

YesNo

Throat Lozenge: *

YesNo

Decongestant:*

YesNo

Antacid:*

YesNo

Antihistamine: *

YesNo

SPECIFIC MEDICAL INFORMATION

Note: Please put NONE, if it do not apply.

1. Allergic reactions (medications, foods, plants, insects, etc.):*

2. Any physical limitations*

3. Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc.? If so, date and disease or condition.*

4. Please describe any other special medical or non-medical conditions of the child?*

RELEASE / INDEMNIFICATION INFORMATION

PARENT/GUARDIAN grants permission for YOUTH PARTICIPANT to participate with the various programs and activities of the Diocese of Fort Worth and/or the PARISH beginning the 1st day of June, 2024 and continuing through the 30th day of June, 2025. These various programs and activities will take place under the guidance and direction of employees and/or volunteers from the PARISH and/or the Diocese of Fort Worth. This permission and liability waiver will be kept on file and will accompany the child on any and all programs and activities of the Diocese of Fort Worth and/or the PARISH. A separate FORM B Consent to Participate and Consent to Emergency Medical Treatment must be filled out and turned in to accompany this form per each program and/or activity.

I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by the participant named above.

I, for myself and my heirs, successors, assigns, personal representatives, and all those claiming by or through me, and on behalf of my spouse, hereby waive and release all claims, now known or hereafter known, against the CATHOLIC DIOCESE of FORT WORTH, any of its parishes, their officers, officials, employees, agents, and volunteers (collectively, the "releasees"), on account of illness, injury, death, or property damage arising out of or attributable to my or my child's participation in these programs or activities, whether arising from the negligence of the releasees or otherwise. I covenant not to make or bring any such claim against any releasee, and forever release and discharge all the releasees from liability under such claims.

I shall defend, indemnify, and hold harmless the releasees against any and all losses, liabilities, claims, causes of action, costs, or expenses of whatever kind, including attorney fees, and costs of enforcing any right to indemnification under this agreement, incurred by or awarded against releasees, arising out of or resulting from any claim of mine, or a third party, related to my or my child's participation in these programs or activities.

Promotional Release

I also consent to the use of any videotapes, photographs, slides, audiotapes, or any other visual or audio reproduction (in perpetuity unless otherwise revoked by me in writing and delivered to the PARISH and by certified mail, return receipt requested, to: The Catholic Center, 800 West Loop 820 South, Fort Worth, TX 76108, ATTN: Director of Youth, Young Adult, and Campus Ministry) in which my son/daughter may appear by the Diocese of Fort Worth. I understand that these materials, including websites and social media sites, are being used for promotion of the youth ministry of the Diocese of Fort Worth which may include recruitment and fundraising efforts.

Social Media Release

The Diocese of Fort Worth utilizes today’s technology in a positive way to reach out to the youth of the Diocese, including Facebook email, and other social media. We may remove any content deemed inappropriate. All communications with any youth through social media programs by anyone representing the Diocese may be made available to any parent upon request. If you do not allow your son/daughter to text, Facebook, or use other social media, there will be no expectation that they do so in order to participate in certain youth ministry events. However, the Diocese cannot guarantee that photos, videos or other communications of your son/daughter from diocesan and/or parish events will not be uploaded to a social media site.

To the best of my ability, everything I have stated here is true and accurately reflects my wishes.

Parent/Guardian/Conservator Signature*

Date (MM/DD/YYYY)

This is your electronic signature*

FORM A

INSURANCE INFORMATION

MEDICAL INFORMATION

SPECIFIC MEDICAL INFORMATION

RELEASE / INDEMNIFICATION INFORMATION

Promotional Release

Social Media Release