(Please print) Participant’s Name: ___________________________________
Age: ________ Birth Date: ______________Girl/Boy:______ Home Telephone: (_________) ________________________
Address: ______________________________________________City/State: ______________________ Zip: ___________
Custodial Parent/Legal Guardian’s Name: __________________________________________________________________
Home Address: _________________________________________ City/State:______________________ Zip:____________
Home Telephone: (_____)_________________ Business (_____)__________________ Cell (_____)___________________
Emergency Contact: ____________ Relationship: ________________ Telephone: ( __)_________________
Second Contact: ______________ Relationship: ________________ Telephone: ( _ )_________________
PARTICIPATION PERMISSION: I, the undersigned, am custodial parent/legal guardian of Participant and request that he/she be to allowed participate in the Activity to be held at __________________________________located in____________________________ on ___________________, including travel time and all events and activities related to said Activity. Transportation is being provided by ___________________________. I understand that in the event Participant fails to conduct herself/himself in a manner consistent with the policies of Epiphany of the Lord Church she/he may be requested to leave the Activity and return home at my expense and that additional disciplinary action may result.
MEDICAL INFORMATION: Is Participant taking any medications OR have any medical conditions (e.g., diabetes, epilepsy, heart conditions, etc.) ____ yes ____ no If yes, explain (attach additional sheets as necessary): _______________________________________________________________________
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): _____________________________________________________________________
Participant’s Primary Physician: _____________________________ Telephone: (_____)_______________
Date of last tetanus immunization: ________________ Health Plan Carrier: ___________________________
Group#:___________________ Policy#:__________________ Name of primary insured: _________________________
_______ (Parent/Guardian Initial)
REQUEST AND AUTHORIZATION TO ADMINISTER MEDICINES: I request and authorize the staff of the Activity to administer the medicines listed below to Participant, as indicated:
Name of Medicine Dosage Frequency 1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
NOTE: All medicines to be taken or administered must be arranged for in advance and must be provided in their original pharmacy container, including the participant's name and doctor's instruction. (Attach extra pages if necessary)
I hereby grant ____ do not grant ______ permission for non-prescription medication (such as non-aspirin products, i.e., acetaminophen or ibuprofen, throat lozenges, etc) to be given to Participant, if deemed appropriate.
Parent/Guardian Signature: ___________________________________________ Date__________________
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 Activity 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 Church, 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 Activity, including the administration of authorized medications, medical treatment and any consequences that may arise as the result of said treatment, including without limitation, travel to and from the Activity, housing, meals and collateral entertainment to the fullest extent permitted by law.
I certify 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 OFF-SITE CONSENT AND WAIVER FORM for YOUTH ACTIVITIES consisting of two (2) pages.
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 Church and that failure to do so may result in my being required to leave the Activity, and not being allowed to participate in future programs or activities, at the discretion of the Parish.