Event - Youth Authorization - R20 - ST. MALACHY ROMAN CATHOLIC CHURCH

Event - Youth Authorization - R20

Diocese of Fresno and all Entities of the Diocese of Fresno:
Permission for a Minor to Participate in a DOF Activity, Release of Liability, and Consent for Emergency Medical Treatment

Parent / Guardian: In order for your child to attend and/or participate in this specific event, activity, or sport listed on this form you must give your signed permission by completing this form. In addition to this form, you must also have on file at your Parish the PR22 Youth Annual Event Authorization.

NAME OF PARISH: St. Malachy Church

NAME OF GROUP: CCD

NAME OF EVENT: K-12

DATE OF EVENT:

OFF CAMPUS FIELD TRIP INFORMATION

DESTINATION OF FIELD TRIP *

CITY/STATE LOCATION *

MODE OF TRANSPORTATION *

FEE (IF APPLICABLE) *

FORM MUST BE RETURNED BY *

DEPARTURE DATE AND TIME *

ESTIMATED RETURN DATE AND TIME *

My child is physically fit and capable of participating in this activity and/or event. I have informed my child to follow the rules, guidelines, and instructions of the DOF Entity and its personnel, as well as the adult leadership of this activity. I understand that participation in this activity involves some risk (including any travel to and from this activity) and that unforeseen occurrences cane arise. I am informed and agree that transportation, if involved, may be provided by volunteers, parents, private individuals, or commercial operators who are believed to be reliable and insured, but are not under the supervision or control of the Diocese.

In exchange for permitting my child to participate in this voluntary activity, I waive and give up all claims (and the right to file a lawsuit) which I or my child (and our successors, heirs, and assigns) may have against DOF. I release and discharge DOF from all liability or responsibility for death, illness, personal injury, or damage arising out of this activity and any transportation involved with this activity.

This permission, waiver, release, and consent applies to the named DOF entity, including, but not limited to the parish; the Diocese of Fresno Education Corporation; the Roman Catholic Bishop of Fresno (a corporate sole); the Diocese of Fresno; other Fresno Diocesan Parishes and schools; affiliated organizations and officers; clergy; agents; and employees.

PARTICIPANT AND PARENT/GUARDIAN AUTHORIZATION

As the parent and/or legal guardian of the named child, I give my permission and consent and agree to all of the forgoing. In the event of an emergency and if the DOF entity is unable to contact me, I authorize the DOF personal or other adult leadership of this even or activity, at my expense , to secure and consent to x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a duly licensed physician, surgeon, or dentist. I expect to be contacted as soon as possible. A copy or digital image of this form shall be valid as the original and my be given to the adult leader of the activity.

* Indicates required field

NAME OF PARTICIPANT *

SIGNATURE OF PARENT/GUARDIAN *

DATE (MM/DD/YYYY) *

HOME PHONE *

CELL PHONE *

OTHER *

MEDICAL INFORMATION

DOCTOR'S NAME OR MEDICAL GROUP *

DOCTOR'S TELEPHONE NUMBER *

INSURANCE COMPANY *

INS. POLICY NUMBER *

Choose Any *

No Family Physician Listed

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