2026 Diocesan Youth Events - Adult Information Form

2026 Diocesan Youth Events - Adult Information Form

Please contact Heather Campbell, Diocesan Youth Minister, at heather@indydio.org if you have any questions or concerns about this form, your responses, or any other information about your participant.
Participant's Full Legal Name*

First NameLast Name
Participant's Preferred Name (if applicable)
She/her/hersHe/him/hisTheythem/theirsOther
Birth Date*

MonthDayYear
Date
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Contact*

First NameLast Name
Emergency Contact Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
WAIVER OF LIABILITY
As an adult participant in 2024 Diocesan Youth Events (each an “Event”), I freely give this Release to the Episcopal Diocese of Indianapolis (“IndyDio”), any parishes or other organizations running the Event, as well as each of their respective subsidiaries, affiliates, officers, wardens, agents, employees, staff, sponsors, legal representatives, administrators, assigns, heirs, executors, those for whom IndyDio is acting and those acting with IndyDio’s authority and permission (collectively as “Releasees”), in consideration for being permitted to participate in the Event.

RELEASE OF ALL CLAIMS. On behalf of myself, I hereby release and discharge Releasees from all present and future liabilities, debts, obligations, costs, expenses, damages, losses, charges, judgments, executions, liens, claims, demands, actions or causes of action of whatever nature or description, in equity or at law, whether caused in whole or in part by the Releasees or any other person or thing at the Event while I am present, which I and each of my family members, estate, heirs, representatives, executors, administrators, successors or assigns (collectively, "Related Parties") may have, whether known or unknown, suspected, asserted or not asserted, arising out of my participation in the Event (collectively, “Claims”), and agree that Releasees are not responsible for any of the foregoing arising out of the Event, even if caused by their own negligence. I understand, acknowledge, and accept that this Release and Waiver of Liability is intended to be binding on me and anyone related to me.

RISKS ACCEPTED. I further understand, acknowledge, and accept that participation in the Event involves certain inherent risks, including, but not limited to, property damage, economic loss, infection by communicable disease, and serious bodily injury (including death), and agree that my participation in the Event is voluntarily with full knowledge of the risks involved and acceptance of all risks of participation.

I agree that should I need medical or dental treatment or need to be transported home for any reason, I shall be liable and agree to pay all costs and expenses incurred in connection with such transportation, medical, and dental services.
Signature*
Date*

MonthDayYear
Date
Participant Medical Information

Please complete the following questions to assure that we have the most up-to-date information to care for your participant in this activity.
Medical Insurance Company*
Name of Insured on Policy*
Policy Number/Group Number*
Insurer Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any special considerations that we should be aware of? This includes special accommodations, medical needs, etc.
Any dietary restrictions?
Any environmental allergies to be aware of?
Please list all medications participant is currently taking.
CONSENT TO MEDICAL AND DENTAL TREATMENT

I hereby authorize the Staff and Volunteers at this Event to consent to emergency medical or dental care, or both for me if I should be incapacitated and unable to consent myself. The authority granted by this authorization includes the authority to consent to an emergency x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my participant. This authority also extends to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act. Strong efforts are to be made to contact provided emergency contact(s) before undertaking anesthesia or emergency surgery. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but it is given to provide authority and power on the part of the Staff and Volunteers in the exercise of their best judgment on what is advisable for my care, upon advice of such physician, dentist, and surgeon.
Signature*
Date*

MonthDayYear
Date
Additional Consents
YesNo
Signature*
Date*

MonthDayYear
Date
Should be Empty:

2026 Diocesan Youth Events - Adult Information Form

WAIVER OF LIABILITY

Participant Medical Information

CONSENT TO MEDICAL AND DENTAL TREATMENT

Additional Consents