Diocese of Kansas City St. Joseph

Church of the Annunciation


(Please Print)

I.                   Event Information



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:_________________ Mobile:_________________ Work:________________

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

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

Text Box: Form: DIO-02-2006Forms will be kept on file in the Office of Youth Ministry for a period of one year following the Event.