School/Parish: Epiphany of the Lord School/Parish Year: 2008 through 2009
REGISTRATION CONSENT AND WAIVER FORM for RE/YOUTH/CDO ACTIVITIES
This Form must be completed and executed for participation in
the RE/Youth Activities as a
part of registration.
(Please print)
Participant’s Name: ______________________________ Birth Date: ___________Age: _____ Girl/Boy: ______
Address: _________________________________________City/State:___________________ Zip: __________
Home Telephone: (_____) ________________
Participant resides with
(check all that applies): Mother ________ Father ________ Guardian(s) __________Custodial Parent/Legal Guardian’s Name: ___________________________________________________
Home Address: ______________________________________ City/State: ______________ Zip: ________
Home Telephone: (_____)_________________ Business (_____)______________
Cell (_____)_________________
Emergency Contact: ____________________ Relationship: ______________________________
Home Telephone: (_____)________________ Cell: ( )________________________________
Second Contact: ____________________ Relationship: ______________________________
Home Telephone: (_____)________________ Cell: ( )________________________________
PARTICIPATION PERMISSION:
I, the undersigned, am custodial parent/legal guardian of Participant and request that he/she be to allowed participate in the RE/Youth programs, events and activities to be held at Epiphany of the Lord parish during the 2008-2009 school/parish year (the "RE/Youth Activities"). I understand that the RE/Youth Activities consist of weekly sessions and related activities which may be held from time-to-time.LOST OR STOLEN ITEMS: I hereby understand and agree that neither the Archdiocese of Oklahoma City or Epiphany of the Lord (Parish/School Name) nor any of their respective employees, directors, officers, agents, representatives and/or volunteers shall be held liable for any of my or my child’s personal property lost or stolen during participation in the RE/Youth Activities.
MEDICAL INFORMATION
: Is Participant taking any medications OR have any medical conditions (e.g., diabetes, epilepsy, heart conditions, etc.)______________________________________________________________________________________________
Does your child have any allergies? (e.g., insects, hay
fever, strawberries, peanuts, etc.)
_____ yes _____ no If yes, explain (attach additional sheets as
necessary):
______________________________________________________________________________________________
Does your child have any allergies or adverse reactions to
medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) ___ yes ___ no
If yes, explain (attach additional sheets as needed):
______________________________________________________________________________________________
Does your child have any disabilities or physical or developmental
limitations? ___ yes ___ no
If yes, explain (attach additional sheets as necessary):
______________________________________________________________________________________________
Date of last tetanus immunization: ___________________
Participant’s Primary Physician: ____________________________Telephone:
(_____)_______________
Health Plan Carrier:
_________________________________________________________________
Group# :_________________________ Policy#:______________________
Name of primary insured: _________________________________________
As a rule, medication will not be administered by RE/Youth Program staff. The exception is an RE/Youth program or activity that includes an extended day or overnight activity. If medication is required a Consent and Waiver Medication Form must be completed prior to the activity.
CONSENT TO TREATMENT of participant:
I am the custodial parent or legal guardian of Participant. I hereby warrant that to the best of my knowledge, Participant is in good health and physically able to participate in the RE/Youth Activities and I assume all responsibility for the health and physical condition and ability of Participant to so participate.In the event of circumstances that indicate that Participant is in need of immediate medical care, I authorize and give permission for Participant to be transported to a hospital/clinic/medical facility for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination. I authorize any licensed physician or medical center to treat Participant. I accept full responsibility for any medical or hospital bills associated with the care of Participant.
LIABILITY WAIVER: In consideration of the arrangement set forth herein, I do on behalf of myself, Participant and our respective heirs, successors, assigns and next of kin, release, waive, hold harmless, defend and covenant NOT TO SUE, Epiphany of the Lord the Archbishop of the Archdiocese of Oklahoma City, and the Archdiocese of Oklahoma City and each of their respective departments, directors, administrators, teachers, officers, agents, representatives, volunteers and employees from any and all actions, claims, demands or liabilities, including without limitation, those for personal injuries or property damage, that I and/or Participant may suffer due to illness or injury suffered by Participant as a result of, or in connection with, participation in the RE/Youth Activities, including the administration of authorized medications, medical treatment and any consequences that may arise as the result of said treatment, including without limitation, housing, meals and collateral entertainment to the fullest extent permitted by law.
I certify to you that the information contained herein is true and correct to the best of my knowledge and that I fully understand the terms and legal consequences of my execution of this REGISTRATION CONSENT AND WAIVER FORM FOR RE/YOUTH ACTIVITIES consisting of two (2) pages.
SIGNATURE:
Custodial Parent/Guardian Name (please print): ___________________________________________________
Custodial Parent/Guardian Signature: ___________________________________________Date____________
ALL PARTICIPANTS FOURTEEN YEARS OF AGE AND OLDER
MUST READ AND SIGN THE STATEMENT BELOW
I acknowledge that I agree to conduct myself in a manner consistent with the policies of the Epiphany of the Lord (
Parish/School Name) and that failure to do so may result in my being required to leave the RE/Youth Activity, and not being allowed to participate in future programs and activities, at the discretion of the Parish/School.SIGNATURE
Participant’s Signature_________________________________________________ Date_________________