VBS Parental Consent, Information, and Release

VBS Parental Consent, Information, and Release

Please fill out a SEPARATE form for each Participant (child)
Program: St. Luke Catholic Church Vacation Bible School.

Parish: St. Luke Catholic Church - Temple, Texas, a non-profit corporation in the State of Texas, including its employees, contractors, clergy, agents, facilitators, and volunteers.

Diocese: Catholic Diocese of Austin, a non-profit corporation in the State of Texas, including its employees, contractors, clergy, agents, facilitators, and volunteers.
Child (Participant's) Name*

First NameLast Name
Child's Grade (2026-2027)*
Name of Parent/Guardian*

First NameLast Name
Phone Number of Parent/Guardian*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Parent/Guardian

First NameLast Name
Phone Number of Parent/Guardian
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone #*
Please enter a valid phone number.Format: (000) 000-0000.

Physician Information
Physician Name
Physician Address
Physician Phone #
Format: (000) 000-0000.

Insurance and Additional Information
Insurance Carrier
Insurance Policy Number
Insurance Address
Insurance Phone #
Format: (000) 000-0000.
Other Information Parent(s)/Guardian(s) Choose to provide

Please read and agree to the following:
1. The undersigned Parent/Guardian represents that they are the parent or legal guardian of Participant (a legal minor) and have full authority under law to sign this document. Parent(s)/Guardian(s) further represents that they agree for Participant listed above to participate in the Program.

2.Parent(s)/Guardian(s) grant their permission for Participant to enroll and participate in the Program.

3. Parent(s)/Guardian(s) acknowledge and agree that:
1. Participant and Parent(s)/Guardian(s) voluntarily seek to participate in the Program;
2. the Program may involve physical activity that involves risk of injury;
3. Participant and Parent(s)/Guardian(s) will abide by all policies and rules established for Program and instructions of those persons facilitating, organizing, or overseeing the Program;
4. Parent(s)/Guardian(s) and Participant are responsible for Participant’s conduct during the Program and are responsible for any damages, claims, or other costs caused by Participant or incurred as a result Participant’s conduct; and
5. if Participant’s conduct is inappropriate, unsafe or detrimental to the Program, other participants or other persons, Parish or the Diocese may suspend or expel Participant from the Program and future Programs.
4. Unless this paragraph is struck and initialed by the undersigned, Parent(s)/Guardian(s) authorize Parish or the Diocese to provide over-the-counter non-prescription pain relievers, cold medicine, and other medications or medical care to Participant at Participant’s request if the Parish or Diocese deem it reasonable to do so. The Parish or Diocese will make reasonable attempts to notify Parent(s)/Guardian(s) prior to authorizing any such non-prescription medication or medical care.
Do you wish to strike Paragraph 4 above?
Initials to strike Paragraph 4.
5. In the event of an emergency or a situation that is reasonably considered to be an emergency, the Parent(s)/Guardians(s) authorize Parish or Diocese to seek and authorize emergency medical care to be given to Participant (for example, first aid, medication, anesthesia) and to transport Participant to the nearest hospital for emergency medical or surgical treatment. Parish or Diocese will make reasonable attempts to notify Parent(s)/Guardian(s) or Emergency Contact (if Parent(s)/Guardian(s) are not available) prior to authorizing any such emergency care. Parent(s)/Guardian(s) will be contacted as soon as possible and will be advised prior to any further non-emergency treatment. If Participant does not have insurance, cash payment in full for the necessary medical treatment is the responsibility of the Parent(s) /Guardian(s).

6. To the extent permitted by law, Parent(s)/Guardian(s), for themselves and for Participant, release and agree to indemnify and hold harmless the Parish and Diocese from any and all liability, claims, demands, and costs which may arise as a result of Participant’s participation in the Program, or which are, in any way, related to the Program. This paragraph covers loss under any theory of loss (negligence or otherwise) including but not limited to personal injury or property damage. The Parent(s)/Guardian(s) and Participant assume all risk of injury or loss to themselves or their property
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Additional Parent/Guardian Signature
Date

MonthDayYear
Date

Name of Parent/Guardian submitting this form*
Email Address*
example@example.com
Should be Empty:

VBS Parental Consent, Information, and Release

Emergency Contact

Physician Information

Insurance and Additional Information

Please read and agree to the following: