Parent/Guardian Consent and Liability Waiver for Boy's Parish Youth Group
All fields are optional unless marked with an asterisk
Boy's Parish Youth Group occurring on various dates
Visitation Parish as part of Lakes Erie & St. Clair Catholic Family of Parishes
Participant’s Name
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First Name
Last Name
Birth Date
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Month
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Day
Year
Date
Home Address
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City
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Province
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Postal Code
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Parent/Guardian and Contact Information
Name of Parent/Guardian
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First Name
Last Name
Relationship to Participant
*
Parent/Guardian Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Medical and Emergency Contact Information
Participant OHIP Number
Family Physician
Family Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all the Participant’s known dietary restrictions, allergies, special medical attention, recent medical procedures/surgeries or other relevant information. *The Diocese will take reasonable care in keeping the Participant’s medical information confidential.
Emergency Contact 1 Name
*
Emergency Contact 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1 Relation
*
Emergency Contact 2 Name
Emergency Contact 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 Relation
Consent and Signatures for Participation
Authorization for Medical Treatment (when applicable):
I/We hereby warrant that to the best of my/our knowledge and belief, the Participant is in good health, and I/we assume all responsibility for the health of the Participant. I/We hereby grant my/our permission for the Diocese of London to make arrangements for medical attention for the Participant without my/our prior approval if emergency treatment is reasonably required and confirm that I/we will be notified as quickly as possible if this authority is exercised.
Media Release
Photos and/or videos may be taken to be used on the Diocese of London websites or social media platforms, in printed materials, or submitted with press releases to local publications to illustrate our community for potential visitors. The Diocese of London will make reasonable efforts not to identify participants by name. The Diocese of London is not responsible if participants disseminate names.
Authorization for Communication
Authorization for Communication: The Diocese of London may provide resources and communications to further develop your family’s understanding of future activities and events, delivered to the Participant’s school, home mailing address, and/or electronically.
Consent, Indemnification & Release of Liability
I/We, on behalf of myself/ourselves, the Participant, my/our and the Participant’s heirs, executors, personal representatives, successors, and assigns, hereby:
• Represent that I am/we are the parent(s), legal guardian(s) or other authorized person(s) or organization with authority over the Participant. • Consent to the Participant participating in the Event, and/or possible use of photo and video. • Confirm that I am/we are aware of the usual risks and dangers inherent in participation in the activities associated with the Event, and that serious injury is possible. • Acknowledge and agree that I/we remain legally responsible for any personal action(s) taken by the Participant, and I/we fully indemnify and save harmless the Diocese of London, its Bishop, parishes, officers, directors, priests, deacons, volunteers, employees and agents, including chaperones or other representatives associated with the Event, from any claim for damages to person or property caused by the Participant. • Forever release and fully hold harmless and shall defend the Diocese of London, its Bishop, parishes, officers, directors, priests, deacons, volunteers, employees and agents, including chaperones or other representatives associated with the Event (the “Diocese of London”), from any and all claims, causes of action and liability of every kind and character, including in connection with any loss or damage to person, property, illness or injury, or cost of medical treatment, arising from or in connection with (directly or indirectly) the Participant participating in and/or attending the Event (collectively, “claims”) save and except for Claims arising from the gross negligence of the Diocese of London.
By signing, I consent to the provisions of the Electronic Commerce Act, and I agree that an electronic copy of this document, including a pdf, fax, or other electronic attachment and/or a copy with my signature and the witness signature or electronic signature(s), shall be equivalent to an original signed by myself under seal. By signing this legal document, you are giving up certain legal rights, including the right to sue in certain circumstances. By signing, you confirm having read all items carefully.
Parent/ Guardian - Signature
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Parent/Guardian - Date
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Month
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Day
Year
Date
Submit
Submit
Should be Empty: