FORM D - Adult Liability Waiver, Medical and Promotional Release Form

Diocese of Fort Worth and/or Parish of*

E-mail of Youth Minister from your Parish*

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

ADULT LIABILITY WAIVER, MEDICAL RELEASE AND PROMOTIONAL RELEASE FORM

**All adults participating in parish and/or diocesan Youth Ministry Events must fill out this form**

Adult Participant’s Name*

DOB (MM/DD/YYYY)*

Address*

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

Phone Number*

Do you text?*

YesNo

Emergency Contact Name*

Relationship to me*

Contact Number*

Health Insurance Carrier*

Insurance ID Number

Insurance Policy Number

You may fill out the ID Number and Policy Number or please email a copy, front and back of your Medical Insurance Card

In the event that I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered. Please advise the doctors that I have the following allergies:

1. Have you gone through the Approved Diocese of Fort Worth Safe Environment Training Program?*

YesNo

If Yes, when*

what parish*

2. Have you read and signed the Code of Conduct and Standards of Behavior from the Diocese of Fort Worth and do you agree to follow the “Code” and “Standards.”*

GUIDELINES FOR ADULT CHAPERONES

It is our request that all adult leaders in each parish/school group help enforce the code of conduct, and to set an example for youth. Please note, adult chaperones must be at least 21 years of age.

The following guidelines have been established to help adult leaders understand their roles and to model appropriate behavior:

There must be 2 compliant adult chaperones for every 10 children during day events and 3 compliant adults for every 10 children during overnight events. a. A minimum of 2 overnight chaperones of the same sex as the participants are required. Example: If an overnight event includes 8 girls and 9 boys, then there are must be at least two male and two female chaperones for the event to enable safe monitoring of the activities during the overnight event/trip.
Chaperones are encouraged to go over event guidelines with youth.
Each Parish/School Leader will be responsible for registration(s) of the group. Chaperones are asked to assist the leader by keep the group safe or helping with the registration process.
Adults are asked to attend all event activities and touch base with youth on a regular basis to answer questions. Please do not leave the event or the event site, and expect other adults to be responsible for the youth of your group (unless it has been arranged by the group leader).
Each chaperone is responsible for completing the Safe Environment Program and be up to date.
Each chaperone must fill out this form and turn it into the group leader. This form will be kept by the leader and is good for one year.
Responsibility for discipline is shared by all adult chaperones. ALL KIDS ARE OUR KIDS! If there is an emergency adult chaperones are expected to call 911 and find the person in charge of the event.
Adults are requested to refrain from drinking alcoholic beverages during the event.
Youth who cause problems should be reported to the Parish/School Leader and then the Diocesan Director (if applicable). “Code of Conduct” violations will result in the parent of the teen being called and the teen being sent home. No Exceptions.
Chaperones are requested to monitor the areas open to the event participants.
Please familiarize yourself with the space(s) being utilized. Youth are not allowed to leave the immediate event area at any time during the event unless it has already been arranged by the youth minister or group leader and the youth’s parent(s).
Each adult chaperone must follow the Code of Conduct of the Diocese of Fort Worth.

I, for myself and my heirs, successors, assigns, personal representatives, and all those claiming by or through me hereby waive and release all claims, now known or hereafter known, against the CATHOLIC DIOCESE of FORT WORTH, any of its parishes, their officers, officials, employees, agents, and volunteers (collectively, the "releasees"), on account of illness, injury, death, or property damage arising out of or attributable to my participation in these programs or activities, whether arising from the negligence of the releasees or otherwise. I covenant not to make or bring any such claim against any releasee, and forever release and discharge all the releasees from liability under such claims.

I shall defend, indemnify, and hold harmless the releasees against any and all losses, liabilities, claims, causes of action, costs, or expenses of whatever kind, including attorney fees, and costs of enforcing any right to indemnification under this agreement, incurred by or awarded against releasees, arising out of or resulting from any claim of mine, or a third party, related to my participation in these programs or activities from June 1, 2024, thru June 30, 2025.

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 by certified mail, return receipt requested, to: The Catholic Center, 800 West Loop 820 South, Fort Worth, TX 76108, ATTN: Director of Youth, Young Adult, and Campus Ministry) in which I may appear by the Diocese of Fort Worth. I understand that these materials are being used for promotion of the youth ministry of the Diocese of Fort Worth which may include recruitment and fundraising efforts.

Signature*

Date (MM/DD/YYYY)

This is your electronic signature*