Dear Parent or Legal Guardian, 

Your son/daughter is participating in a parish activity at St. John Fisher Chapel University Parish. The activity will take place under the guidance and supervision of volunteers from St. John Fisher Chapel University Parish. 

Location: St. John Fisher Chapel University Parish 

Designated Supervisor of Activity: Anna Picklo 

Date & Time: Monday August 3rd - Friday August 7th, 9-12pm 

Student Cost: $35 /student 

In order for your child(ren) to participate in this event, please complete, sign and submit the following statement of consent and release of liability and medical release. As a parent ot legal guardian, you remain fully responsible for the actions and conduct of your child(ren). 

I hereby consent to the participation of my child in the event described above. I understand that it will take place on the church grounds and that my child will be under the supervision of the designated church employee on the stated dates. I Further consent to the conditions stated above on partipication in this event. 

In consideration of my child being allowed to participate in this event, I hereby agree on behalf of myself and my child to release St. John Fisher Chapel University Parish, the Roman Catholic (Arch)diocese of Detroit, and any and all affliated organizations, their employees, agents and representatives, including volunteer drivers (collectively "Releases"), 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 Vacation Bible School. In the event on behalf of myself and/or my child is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releases from any and all claims, including negligence, which may be asserted by me or my child, arising from or relating to my child's participation in Vacation Bible School. This release of indemnification apply to the extent of commerical 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. 

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 nesscary and appropriate. This authority is granted only after reasonable effort has been made to reach me. 

This form is intended for use only during the above idenitified event. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes. 

I further authorize the person who presents the minor to sign the acknowledgement of Recipt 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. I acknowledge that it is my responsibility to submit a new form if any of the above information changes.