Form A - Annual Youth Ministry Parental Liability Waiver, Permission and Medical Information

Catholic Diocese of Fort Worth and/or the Parish of *

Youth Participant's Name *

Birth Date *

- Month - Day Year

Sex *

Male Female

Parent/Guardian Name *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

- Area Code Phone Number

Texting

Yes No

E-mail of Youth Participant *

Email of Youth Minister from your Parish *

This email ensures your Youth Minister is sent a copy of this form.

Emergency Contact Name (other than parent/guardian) *

Relationship to the YOUTH PARTICIPANT *

Primary Phone Number *

- Area Code Phone Number

Texting *

Yes No

Insurance Information

Is the participant insured? *

Yes No

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

Insurance Carrier/Name of Insurance Co

Policy Number

Insurance ID Number

Claim Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Customer Service Phone #

- Area Code Phone Number

Medical Information

Prescriptions and Medications: *

This child takes no medication and will bring no medication with him/her. This child takes medication but is unable to self-medicate. The child’s parent/guardian/conservator will provide and dispense any and all needed medications. This child takes medication(s) and will self-medicate. The child will bring all such medications necessary, and such medications will be clearly labeled. I understand that the child will be required to turn all medication(s) over to a supervising adult designated to keep medication(s). I further understand that it will be this child’s responsibility to present himself/herself at a location designated for returning medication(s) to this child at the frequencies/times listed below. I understand that the adult to whom this child surrenders the medication has no medical training and this adult will not measure dosages. This child will return the medication(s) to the adult after he/she self-medicates. At the conclusion of the event it will be this child’s responsibility to pick up remaining medication(s), if any, at the self-medication designated location. Names of medications and exact dosage and frequencies/times are as listed below: (you may attach a sheet to this form if you need more space just make sure to sign and date it as well).

Names of medications and exact dosage and frequencies/times

Over-The-Counter Medication Permission: *

No medication of any type whether prescription or nonprescription may be administered to this child unless the situation is life-threatening and emergency treatment is required. I grant permission for the following nonprescription medication to be given to this child in the recommended dosage on the medication bottle.

Non-aspirin pain reliever:

Yes No

Throat Lozenge:

Yes No

Decongestant:

Yes No

Antacid:

Yes No

Antihistamine:

Yes No

1. Allergic reactions (medications, foods, plants, insects, etc.): *

Please put NONE, if it do not apply.

2. Any physical limitations *

Please put NONE, if it do not apply.

3. Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc.? If so, date and disease or condition. *

Please put NONE, if it do not apply.

4. Please describe any other special medical or non-medical conditions of the child? *

Please put NONE, if it do not apply.

Release/Indemnification Information

PARENT/GUARDIAN grants permission for YOUTH PARTICIPANT to participate with the various programs and activities of the Diocese of Fort Worth and/or the PARISH beginning the 1st day of June, 2018 and continuing through the 31th day of May, 2019. These various programs and activities will take place under the guidance and direction of employees and/or volunteers from the PARISH and/or the Diocese of Fort Worth. This permission and liability waiver will be kept on file and will accompany the child on any and all programs and activities of the Diocese of Fort Worth and/or the PARISH. A separate FORM B Consent to Participate and Consent to Emergency Medical Treatment must be filled out and turned in to accompany this form per each program and/or activity.

I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by the participant named above.

I agree on behalf of myself, the above named YOUTH PARITICIPANT, our/his/her heirs, successors, and assigns to hold harmless, the Diocese of Fort Worth, the Bishop and his successors, employees, agents, volunteers, the Parish, its employees and volunteers from any and all claims (unless due to the negligence of the Diocese and/or Parish) for illness, injury, death and the cost of medical treatment therewith, arising from or in any way connected with my son’s/daughter/participant’s attending the various programs and activities during the dates named above.

In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this agreement, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, reasonable attorneys’ fees and expenses incurred by the prevailing party.

Promotional Release

I also consent to the use of any videotapes, photographs, slides, audiotapes, or any other visual or audio reproduction (in perpetuity unless otherwise revoked by me in writing and delivered to the PARISH and by certified mail, return receipt requested, to: The Catholic Center, 800 West Loop 820 South, Fort Worth, TX 76108, ATTN: Director of Youth Ministry and Adolescent Catechesis) in which my son/daughter may appear by the Diocese of Fort Worth. I understand that these materials, including websites and social media sites, are being used for promotion of the youth ministry of the Diocese of Fort Worth which may include recruitment and fundraising efforts.

Social Media Release

The Diocese of Fort Worth utilizes today’s technology in a positive way to reach out to the youth of the Diocese, including Facebook email, and other social media. We may remove any content deemed inappropriate. All communications with any youth through social media programs by anyone representing the Diocese may be made available to any parent upon request. If you do not allow your son/daughter to text, Facebook, or use other social media, there will be no expectation that they do so in order to participate in certain youth ministry events. However, the Diocese cannot guarantee that photos, videos or other communications of your son/daughter from diocesan and/or parish events will not be uploaded to a social media site.

To the best of my ability, everything I have stated here is true and accurately reflects my wishes.

Parent/Guardian/Conservator Signature *

Date

- Month - Day Year

If you do not wish to sign this document electronically, please print the document, sign, and mail to your parish.