Diocese of
Church of the Annunciation
PARTICIPATION FORM FOR YOUTH MINISTRY
EVENTS
(Please Print)
I.
Event Information
Event:_____________________________________________________________________
Destination:_________________________________________________________________
Date/Time
of Departure:_______________________________________________________
Date/Time
of Return:__________________________________________________________
Method
of Transportation: ______________________________________________________
Participation
Cost:____________________________________________________________
II.
Participant Information
Name of
Participant:____________________________________________________________
Gender:___________ Date of Birth:__________________ SSN:___________________
Name of
Parent/Guardian:________________________________________________________
Home
Telephone:_________________
Other
Contacts in case of illness or injury:
Name/Phone:___________________________________________________________________
Name/Phone:___________________________________________________________________
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
Physician's
Name/Telephone:______________________________________________________
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.