Consent Form & Liability Waiver




Event Name
Participant`s Name
Parent/Guardian Name
Home Address
Home Phone
Cell Phone Number
I grant permission for the above child to participate in this parish youth ministry event that requires transportation to a location away from this parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from Our Lady of Mount Carmel Church. I also grant permission to use any photos taken of my child during this event for church-related events and promotions.  Checking this box will serve as my signature.
Signature
Destination of event
Departure Date
Return Date
As parent and/or legal guardian, I remain legally responsible for any personal actions take by the above named minor ("participant"). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Mt. Carmel Church, its officers, directors, and agents, and the Diocese of Baton Rouge, chaperons, or representatives associated with the event for reasonable attorney's fees and expenses arising in connection therewith. Checking of this box will serve as my legal signature.
Signature
Date
Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsiblity for the health of my child.
 
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name & Relationship
Phone #
Family Doctor
Doctor`s Phone
Name of Insurance Company
Policy Number
Group Number
Specific Medical Information: The parish will take reasonable care to see that the following information will be held in confidence. Under medications please list name and dosage of any medications that must be taken.
List Allergic Reactions:
Physical limitations?
Date of Last Tetanus Injection
Medications
Checking this box will serve as my legal signature.
Parent`s Signature
Date Signed
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