Form A

Catholic Diocese of Fort Worth and/or the Parish of

Youth Participant:

Name

Birth Date

Sex

Parent/Guardian/Conservator:

Name

Home Address

(Please enter Street Address, City, State, Zip Code)

Cell Phone

Texting

E-mail of Parent

Email of Youth Minister / DRE from your Parish

(This email ensures your Youth Minister is sent a copy of this form. Please enter the correct email address.)

Emergency Contact:

Emergency Contact Name (other than parent/guardian)

Relationship to the Youth Participant

Primary Phone Number

Texting

INSURANCE INFORMATION

Is the participant insured?

Name of Policy Holder (whose name is the policy in)

Insurance Carrier/Name of Insurance Co

Policy Number

Insurance ID Number

Claim Address

(Please enter Street Address, City, State, Zip Code)

Customer Service Phone Number

MEDICAL INFORMATION

Prescription and Other Medications:

Medication requirements and procedures may vary by program or activity. I agree to provide complete and current medication information and to notify the participating parish, school, or ministry of any material changes. Medication brought to a program or activity must be in its original labeled container. Additional authorization or documentation from a licensed health care provider may be required.

Please select one:

Participant takes medication and is capable of self-administering it. I authorize program personnel to receive, securely store, and make the medication available to Participant for self-administration. Participant is expected to take the medication according to the written instructions and to report to designated personnel as directed. Program personnel will not determine, measure, or modify the prescribed dosage or schedule. I am responsible for retrieving any remaining medication at the conclusion of the event and authorize the program to dispose of medication not retrieved in accordance with applicable law and appropriate disposal procedures.

List all medications Participant may need during programs or activities, including the medication name, dosage, times or circumstances for use, and any special instructions:

Does Participant need to carry or have immediate access to any medication, such as an epinephrine auto-injector or rescue inhaler?

If yes, identify the medication:

I understand that arrangements for Participant to carry or have immediate access to medication must be coordinated with the participating parish or ministry and may require additional medical authorization or documentation.

Medication Handling Authorization: By providing medication for Participant, I authorize program personnel to receive, securely store, handle, and make medication available to Participant for authorized self-administration. Except for nonprescription medication expressly authorized below, or emergency assistance otherwise authorized, program personnel will not administer medication to Participant.

OVER-THE-COUNTER MEDICATION PERMISSION:

Please select one:

Authorized nonprescription medications:

Throat Lozenge:

Decongestant:

Antacid:

Antihistamine:

Non-aspirin pain reliever:

SPECIFIC MEDICAL INFORMATION

Note: Please put “NONE” or “N/A” if it is not applicable.
List all medications Participant may need during programs or activities, including the medication name, dosage, times or circumstances for use, and any special instructions.

1. Allergies and reactions (medications, foods, plants, insects, etc.). Please describe the allergy, typical reaction, and any emergency medication or instructions:

2. Physical limitations or medical restrictions:

3. Other medical conditions or information that program personnel should know to help protect Participant's health and safety:

RELEASE / LIMITED INDEMNIFICATION / AUTHORIZATIONS

Permission to Participate

I, the undersigned parent, legal guardian, or conservator (“Parent/Guardian”), give permission for the youth Participant identified above (“Participant”) to participate in programs and activities sponsored, conducted, or approved by the Catholic Diocese of Fort Worth and/or the participating parish, school, or ministry beginning June 1, 2026, and continuing through June 30, 2027. Activities may occur on or away from parish, school, or diocesan property and may include transportation provided or arranged in connection with an activity. A separate Form B — Consent to Participate and Consent to Emergency Medical Treatment must be completed for each program or activity as required by diocesan policy.

For purposes of this Agreement, the “Releasees” are the Catholic Diocese of Fort Worth; the parish, school, ministry, or other diocesan entity sponsoring, hosting, or participating in the applicable program or activity; and their respective Bishop, successor Bishops, clergy, religious, officers, directors, employees, agents, and volunteers.

Authority to Sign

I represent and warrant that I have authority to consent to Participant's participation. If any other parent, legal guardian, or conservator (an “Other Parent”) has legal rights with respect to Participant, I further represent and warrant that I am authorized to execute this Agreement on that person's behalf, including authority to release that person's own claims arising from the ordinary negligence of the Releasees, unless I notify the participating parish, school, or ministry in writing, before or when I sign this Agreement, that I lack such authority. The Releasees may rely on these representations without requiring the signature of any Other Parent.

Assumption of Risk

I understand and voluntarily accept that participation involves ordinary and inherent risks of illness, accident, bodily injury, property damage, serious injury, or death, including risks associated with physical or recreational activities, transportation, weather, premises or equipment, interactions with others, and other circumstances of participation.

IMPORTANT — RELEASE OF CLAIMS, INCLUDING ORDINARY NEGLIGENCE

TO THE FULLEST EXTENT PERMITTED BY TEXAS LAW, I, INDIVIDUALLY AND AS AUTHORIZED AGENT FOR ANY OTHER PARENT WHOM I AM AUTHORIZED TO BIND, WAIVE, RELEASE, AND DISCHARGE THE RELEASEES FROM CLAIMS BELONGING PERSONALLY TO ME OR TO SUCH OTHER PERSON ARISING OUT OF OR RELATING TO PARTICIPANT'S PARTICIPATION, INCLUDING CLAIMS FOR ILLNESS, PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE, EVEN IF CAUSED IN WHOLE OR IN PART BY THE ORDINARY NEGLIGENCE OF A RELEASEE.

This release applies only to ordinary negligence. It does not apply to gross negligence, reckless conduct, willful or intentional misconduct, or any other liability that applicable law does not permit to be waived or released.

I agree not to bring or maintain any claim released by this Agreement. To the fullest extent permitted by law, I also waive and release any claim relating to Participant's participation that I am legally authorized to waive or release on Participant's behalf.

Participant Conduct

Participant is expected to follow applicable rules, safety instructions, codes of conduct, and reasonable directions. To the extent permitted by law, I agree to be responsible for property damage or other loss caused by my own wrongful conduct or Participant's intentional or willful misconduct.

Limited Indemnification

To the extent permitted by law, I agree to indemnify and hold harmless the Releasees from and against losses, liabilities, damages, judgments, reasonable settlement amounts, costs, and expenses, including reasonable attorneys’ fees and defense costs, arising from (a) third-party claims for bodily injury or property damage, but only to the extent caused by my negligent or intentional conduct or Participant’s intentional or willful misconduct; and (b) any claim brought by an Other Parent whom I have represented and warranted that I am authorized to bind, but only to the extent that the claim would be released under this Agreement if asserted by me, including a claim caused in whole or in part by the ordinary negligence of a Releasee.

If a Releasee successfully enforces against me the release, covenant not to sue, or indemnification obligation under this Agreement, I shall be responsible for the Releasee’s reasonable attorneys’ fees and court costs incurred in such enforcement, including those incurred on appeal.

Nothing in this Agreement is intended to waive, release, or create an indemnification obligation for any claim belonging independently to Participant that applicable law does not permit a parent, legal guardian, or conservator to waive, release, or indemnify.

Severability and Governing Law

Texas law shall govern this Agreement. If any provision or portion of this Agreement is determined to be invalid or unenforceable, it shall be enforced to the maximum extent permitted by law, and the remaining provisions shall remain in effect.

Promotional Release

I authorize the Catholic Diocese of Fort Worth and the participating parish, school, or ministry to photograph, video record, or audio record Participant during programs and activities and to use Participant’s image or voice, without compensation, in publications, websites, social media, and other communications for informational, educational, promotional, recruitment, or fundraising purposes. This authorization applies without time limitation to photographs and recordings made during the period covered by this Form A.

Electronic Communications Consent

I give permission for authorized ministry personnel to communicate with Participant regarding programs and activities by text message, email, messaging applications, social media, and other electronic means. I understand that I may request access to electronic communications sent by ministry personnel to Participant.

Acknowledgment