Holy Trinity Youth Group

Child's Name

First NameLast Name

Grade

Mother/Guardian's Name

Mother/Guardian's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Father/Guardian's Name

Father/Guardian's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email (will be used for updates)

example@example.com

Please list the name and phone number of an additional emergency contact:

Per the diocese, we have to ask for the following information regarding your child's medical information.

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.

Doctor Name & Phone Number

Health Insurance Carrier

Policy #

List any allergies that your child has:

Is there any other information about your child that you want to share with youth leaders and parish staff?

I hereby grant permission for non-prescription medication (such as Tylenol, throat lozenges, etc.) to be given to my child, if deemed advisable.

I give permission for photographs/videos of my child to be used for parish, school, and/or diocesan communications and promotional programs. I understand that any photographs/videos will be used only in a legal manner and that at no time will my child be depicted in any unethical manner. No personal identification information, such as name or address, will be posted with photographs/videos.

Emergency Medical Treatment Permission
In the event of an emergency, I/we hereby give permission to transport my/our child to a hospital for treatment by the hospital or doctor. I wish to be advised prior to any further treatment by the hospital or doctor. I/we further give my/our permission for health officials to release medical information on my/our child to the diocesan group leader, if applicable.

Liability Waiver
I/we agree, on behalf of myself/ourselves, my/our child named herein, my/our and my/our child’s heirs, successors and assigns, to hold harmless and defend the parish and the Diocese of Springfield-Cape Girardeau, their officers, directors, employees, volunteers, agents, chaperones, and representatives associated with the event, from any claim arising from or in connection with my/our child attending the event, from any claim arising from or in connection with any illness or injury (including death) or in connection with the cost of medical treatment as a result of an illness or injury, even if the cause of damages or injury is alleged to be the fault of or caused by the negligence of the parish or the Diocese. I/we agree to compensate the parish or Diocese, their officers, directors, employees, agents and chaperones or representatives associated with the event for reasonable attorney’s fees and expenses which they may incur in any action brought against them as a result of such injury or damage, unless such a claim arises from the negligence of the parish or Diocese.

I/we warrant that the information herein is correct to the best of my/our knowledge.

I/we fully understand and sign this Parental/Guardian Consent Form and Liability Waiver knowingly, freely and willingly.

Signature