OFF-SITE CONSENT AND WAIVER FORM for YOUTH ACTIVITIES

This Form is required from all youth for trips/activities, including field trips, outside your local area (more than sixty (60) miles from your church or school). It must be used for all overnight trips.

 

Name of Activity_____________________  (hereinafter referred to as the Activity and more fully described below).

(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 Activity to be held at the _________________________________ ____________________________________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.

 

LOST OR STOLEN ITEMS: I hereby understand and agree that neither the Archdiocese of Oklahoma City or Epiphany of the Lord Church 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 Activity.

 

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):

______________________________________________________________________________________________

Date of last tetanus immunization: ___________________

Participant’s Primary Physician:  ________________________________ Telephone: (_____)_______________

Health Plan Carrier: ______________________________________________________________________________

Group#:_________________________ Policy#:______________________

Name of primary insured: _________________________________________________________________________

 

                                                                                                                                                                                _______ (Parent 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 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 OFF-SITE CONSENT AND WAIVER FORM FOR YOUTH 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 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/School.

 

SIGNATURE

Participant’s Signature_________________________________________________ Date­­­­­­­­­­­­­­­­­­­­_________________