2024 Loaves & Fishes - Parental/Guardian Consent Form and Indemnity Agreement

I parent name* grant permission for my childparticipant/child name* to participate in this parish event that requires transportation to a location away from the parish site. This event will take place under the guidance and direction of parish employees and/or volunteers from St. Mary of the Lake Catholic Church.
A brief description of the activity follows:

Type of Event: Loaves & Fishes - Serve dinner with Loaves & Fishes to about 250 guests. Help with setting up, interacting with guests, serving the meal, and cleaning up.

Date of Event: Wednesday, December 20 from 3:15 (meet at St. Mary's to Carpool) until 6:00 PM (return to St. Mary's)

Cost: Free.

Destination of Event:

Richard Schultze Opportunity Center

422 Dorothy Day Place

St. Paul, MN 55102

Individual(s) in charge: Michelle Boris; office: (651) 429-7771, option 1| cell: (612) 405-8703 | e-mail: mboris@stmarys-wbl.org, St. Mary's chaperones

Estimated Time of Departure: 3:15 PM from St. Mary of the Lake Parish Life Center Parking Lot

Estimated Time of Return: Approximately 6 PM to PLC

Mode of Transportation To & From Event: Chaperone vehicles
I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“student/participant”). Further, 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.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Mary of the Lake, its officers, directors, employees and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter “Releasees”), from any claim, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Releasees and is not related to communicable disease (see communicable disease release, hold harmless and indemnification agreement below).

Communicable Disease Release, Hold Harmless & Indemnification Agreement: I agree to hold Releasees harmless, release, defend, and indemnify Releasees for any communicable disease claim arising out of the above Event that is brought against Releasees by myself, participant, my family members, heirs, assigns, executors, and personal representatives. I understand and agree this communicable disease release, hold harmless, and indemnification agreement includes claims based on the actions, omissions, or negligence of participant, myself, and others, including, but not limited to the Releasees.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name.*

First NameLast Name
Date*

MonthDayYear
Date

Medical Matters
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.*

Yes, I agree.No, I do not agree (I understand that my child will not be able to participate in this event).
In the event of an emergency, if you are unable to reach me at the above numbers, contact: *

First NameLast Name
Relationship*
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Home Phone Number

Area CodePhone Number
Specific Medical Information

St. Mary of the Lake will take reasonable care to see that the following information will be held in confidence.
Medications: My child is taking medication at present. My child will bring all such medications necessary and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:*

Yes, my child is taking medications.No, my child is not taking any medications.
Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:*
Allergic reactions (medications, foods, plants, insects, etc.): *
Immunizations: Date of last tetanus/diphtheria immunization: *
Does child have a medically prescribed diet? *
You should be aware of these special medical conditions of my child (such as anxiety, ADHD, depression, asthma, diabetes, etc.) :*
Family Doctor/Physician's Name*
Family Doctor/Physician'sPhone Number*

Area CodePhone Number
Family Health Plan Carrier*
Policy/Identification/Group Number*

Submission Page
As Parent or Guardian, I agree to all of the above stated considerations and conditions.*

Check here to agree.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name.*

First NameLast Name
Date*

MonthDayYear
Date
Please verify that you are human*
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High School Youth Ministry Loaves & Fishes December 18, 2024 - Parental/Guardian Consent Form and Indemnity Agreement

Medical Matters

Submission Page