* Parent/Guardian Phone
* Participant Phone
Male or Female
Spring Retreat at Damascus Catholic Mission Campus
April 5th, 2019-April 7th, 2019
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
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 Person of Contact
* Parent or Person of Contact
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
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.
ADULT CODE OF CONDUCT
1. Adults shall at all times conduct themselves in a lawful manner appropriate to the Activity.
2. Adults shall act with respect for all other participants in the Activity.
3. Adults shall act in accordance with the principles of the Roman Catholic Church.
4. Adult participants shall at all times be present and shall chaperone students assigned by group leader.
5. Adult participants will supervise and monitor the movement of students throughout the activity.
6. Adult participants will insure that no .students enter areas specifically prohibited.
7. Adult participants will insure that no students enter any rooms or areas that are not appropriately chaperoned by two adults.
8. Adult participants will use safe environment practices such as not meeting with students in secluded areas; making sure enough adults are chaperoning all activities; observing other adults who are interacting with youth; and notifying OYYAM staff of any inappropriate activities throughout the duration of the activity.
9. Adult participants will respect that the sessions are designed for the benefit of students and will refrain from excessive questions or participation in the sessions.
10. The possession or use of alcohol, tobacco, drugs, or weapons of any kind by students or adult participants is not permitted.
11. Failure to abide by this Code of Behavior may result in a request for the adult to leave the premises.
Participant's Digital Signature
* Participant's Digital Signature
Parent or Legal Guardian's Digital Signature
* Parent or Legal Guardian's Digital Signature
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