Church of the Annunciation
PARTICIPATION FORM FOR YOUTH MINISTRY EVENTS
I. Event Information
Date/Time of Departure:_______________________________________________________
Date/Time of Return:__________________________________________________________
Method of Transportation: ______________________________________________________
II. Participant Information
Name of Participant:____________________________________________________________
Gender:___________ Date of Birth:__________________ SSN:___________________
Name of Parent/Guardian:________________________________________________________
Other Contacts in case of illness or injury:
III. Participant Health Information (Required only for events more than 6 hours in duration)
Are you in general good health and able to participate in normal activities?_____Yes _____No
If No, describe your limitations:_________________________________________________
Identify any over-the-counter medications you will be bringing to the event:_________________
All immunizations up to date?____Yes ____No
Participant's Health Insurance Provider:______________________________________________
Policy or Group#_______________________________________________________________
Primary Policyholder's Name : ____________________________________________________
Optional Information (provide to the extent you feel is appropriate):
Identify any prescription medications you are taking, and frequency of dosage:_______________
Identify any special dietary restrictions:______________________________________________
Allergies, diseases, disorders, disabilities, surgeries or serious injuries:______________________
IV. Permission of Parent/Guardian
I/We, the parent(s)/guardian(s) of _____________________________________, request that he/she be allowed to participate in the Event described above, and hereby give my/our permission for such participation.
I/We give my/our permission to the sponsoring Diocese/Parish/School/Organization to take photographs, video or digital images of Participant during the Event for future promotional purposes.
V. Consent for Disclosure to Individual Involved in the Care and Treatment of Participant
For the duration of the Event, I/We grant to the Diocese/Parish/School/Organization and its agents the following powers, to be used for the benefit of and on behalf of Participant (check all that apply):
_____ to receive any and all individually identifiable health information about the past, present and future medical condition of Participant, including, but not limited to, information necessary to the care and treatment of Participant and any illness or injury Participant may have sustained;
_____ to authorize medical care for Participant, including, but not limited to, any and all treatment, examination, diagnosis or outpatient medical care rendered under the general or special supervision of and on the advice of any physician or surgeon licensed to practice medicine by the applicable licensing body in the state in which physician or surgeon practices.
I/We understand that the Diocese/Parish/School/Organization will not be liable to me/us or any or my/our successors in interest for any action taken or not taken in good faith.
I/We consent to the logistics and conditions described above, including the method of transportation.
I/We understand that as parent(s) or legal guardian(s) I/we may be responsible for any liability which may result from the conduct of Participant at or during the Event.
I/We understand that there is a risk of injury involved in any Youth Ministry activity. I/We hereby release the Diocese of Kansas City-St. Joseph, and its officers, agents, employees and volunteers, from any liability arising from claims of any kind or nature whatsoever in connection with Participant's participation in the Event.
Signature of Parent/Guardian Date
Signature of Parent/Guardian Date
Forms will be kept on file in the Office of Youth Ministry for a period of one year following the Event.