B.A.S.I.C. Cedar Point Trip 2024

***********************STATEMENT OF CONSENT*************************

Event Name: BASIC Cedar Point Trip

I hereby consent to participation by my child,   Name*   , in the event described above. I understand that this event will take place away from the school/parish grounds and that my child will be under the supervision of the designated school/parish employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.

In consideration of my child being allowed to participate in this field trip, I hereby agree on behalf of myself and my child, to release St. Anastasia Catholic Church, the Roman Catholic (Arch)diocese of Detroit, and any and all affiliated organizations, their employees, agents and representatives, including volunteer drivers (collectively “Releasees”), from any and all claims, including negligence, which may be asserted by me or my child, or on behalf of my child, arising from or relating to my child’s participation in the field trip. In the event this release on behalf of myself and/or my child is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releasees from any and all claims, including negligence, which may be asserted by me or my child, or on behalf of my child, arising from or relating to my child’s participation in the field trip. This release of indemnification does not apply to claims for intentional misconduct or gross negligence; nor does this release or indemnification apply to the extent of commercial insurance coverage for any claim, but this Release or Indemnification shall apply to the extent of any self-insurance or deductible applicable to any claim.

MEDICAL TREATMENT RELEASE FORM

To Whom It May Concern:

As parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor:   *        Relationship to you:   *   

Reason for which release is intended: Cedar Point Trip or event

Address of Minor:   Street Address*      City*   State*   Zip*   

Emergency Phone(s):   *   

Family Physician:   *    Phone:   *   

Physician Address:   Street Address*      City*   State*   Zip*    

Health Insurance Data:  

Company: *    Policy:   *   

Group:   *    Contract:   *   

I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. 

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.

Date:   Date*                        Signed: Signature*   

                                                                        (Parent or Guardian)

PSI/MedRel/05-94

HAPS-March 2004

RELEASE FOR DISPENSING OF MEDICATION (IF APPLICABLE)

We, the undersigned parent and/or guardian of:
 
Name *   Grade*     Born   Date      
(Student's Name)             (Grade)             Mo Day Yr
 
do hereby sign and execute this release on behalf of us and on behalf of our minor son/daughter/ward.
 
NAME OF MEDICATION:   *   
                                DOSE:   *   
        TIME TO BE GIVEN:   *   
                      DURATION:   *   
 
ATTACH DOCTOR’S NOTE REGARDING EMERGENCY CARE PLAN AND ADMINISTRATION OF MEDICATION.
       
Please Select Check (yes) No check (no)    Check here, if this release is for a metered dose asthma inhaler, insulin pump or epinephrine auto-injector, which the student will possess and use at his/her own discretion in school or at school activities. The physician and parents/guardian signature below apply to the inhaler, insulin pump or epinephrine auto-injector possession and use by students as permitted in Public Act 10 – Revised School Code.
 
Signature       Name*        Date
(Doctor's Signature)                     (Please Print Name)                        (Date)
(Signature only required if the medication is not kept in the labeled pharmacy container)

Phone Number* 

(Phone Number)

We hereby waive any liability whatever to the school or the Archdiocese of Detroit or any of its personnel, that might occur as the result of giving said medication in the indicated dosage at the time requested to our minor son/daughter/ward.
 
PARENT/GUARDIAN  
        Signature

                                                                                                                              (Signature)

Name*     

                                                                                                                          (Print Name)

DATE    Date       

(April 2017) This form MUST accompany any medications being brought on to the event