Participant Cell Phone
* Participant Cell Phone
The undersigned hereby state(s) that (he/she/they) (is/are) the (parent/parents/guardian) of the above named Participant and have full legal responsibility for the Participant. The undersigned hereby grant(s) permission for the Participant to participate in the Activity named in Section I.B., above.
III. RELEASE AND INDEMNIFICATION
A. Release. The undersigned on behalf of the undersigned, the Participant, and the heirs, successors and assigns of the undersigned and the
Participant, hereby release, hold harmless from any liability, and discharge from all direct or derivative claims, actions, causes of actions, medical expenses, costs, legal expenses, other expenses and all other damages at law or in equity, known or unknown, direct or indirect, choate or inchoate against the Diocese of Columbus, the Parish and all current and former employees, agents, clergy, officers and volunteers of the Diocese of the Parish, arising from the Participant’s participation in the Activity named in Section I.B., above.
B. Indemnification. The undersigned shall indemnify and hold harmless the Diocese of Columbus, the Parish, and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish from any claim, liability, suit, judgment, loss, damage, expense, fee or cost (including court costs and attorney fees) arising directly or indirectly from the Participant’s participation in the Activity named in Section I.B., above, unless arising from the negligence of an indemnified party.
IV. SPECIFIC MEDICAL INFORMATION AND MEDICATION
A. Specific Medical Information. The Parish will take reasonable care to see that the following information will be held in
Allergic Reactions/Dietary Needs
Should we be aware of any special medical conditions of the Participant?
C. Non-Prescription Medication
Please check one of the following
Non-prescription medication may be given to the Participant, if deemed appropriate.
No medication, prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required.
V. EMERGENCY MEDICAL CONTACT AND TREATMENt
Parent or Guardian
* Parent or Guardian
Medical Insurance Provider
B. Emergency Medical Treatment
In the event of an emergency, the undersigned hereby give(s) permission to transport the Participant to a hospital for emergency medical or surgical treatment. The undersigned wish(es) to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if the undersigned cannot be reached at the above numbers, contact:
* In the event of an emergency, the undersigned hereby give(s) permission to transport the Participant to a hospital for emergency medical or surgical treatment. The undersigned wish(es) to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if the undersigned cannot be reached at the above numbers, contact:
Relationship to Participant
VI. CONSENT FOR RELEASE OF PERSONALLY IDENTIFIABLE INFORMATION
The undersigned hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus and St. Catharine of Siena for future promotional programs of the Diocese and Parish. If you have any questions or concerns, please contact Brendan O'Rourke at 614-231-4509
Check here if you DO NOT consent to the release of personally identifiable information.
The Participant shall comply with the following:
1. The Participant must stay and participate in the entire event. The Participant may not leave the premises unless accompanied by an adult leader, parent, or legal guardian.
2. The possession or use of alcohol, tobacco, drugs, or weapons of any kind is not permitted.
3. Foul language is not tolerated.
4. The Participant must comply with any and all directions of activity staff.
5. The Participant must respect the rights and property of others. Damage to or defacing of property will be the financial responsibility of
the Participant involved and the undersigned.
6. Failure to abide by this Code of Behavior may result in a request to the undersigned to transport the offending Participant from the
premises, and the undersigned shall immediately comply with the request.
Participant's Digital Signature
* Participant's Digital Signature
Parent or Legal Guardian's Digital Signature
* Parent or Legal Guardian's Digital Signature
If you want to pay online via St. Catharine's secure online giving site,
If you or your family already gives to the parish, simply use their information to login, otherwise you can create your own account. Then follow these steps:
"Give a New Gift"
"Youth Group Events" choose "One Time"
$115.00 in the Amount space
4. Enter "Kick off retreat" in the Special Intentions space
"Next" at the bottom of the page