Publication

ARCHDIOCESE OF BALTIMORE PERMISSION FORM AND RELEASE
Home Phone:____________ Work Phone: ____________ Emergency Contact (name and telephone number): As parent or guardian of my son/daughter, I do hereby agree to allow my son/daughter to participate in the following activity
(event/date/time): D.C. Pentecost Pilgrimage/ (5/26/2012)/ 9:30am-7:30pm
I acknowledge receipt of the attached information sheet describing the planned activity. In consideration of the opportunity for my son/daughter to participate in the activity, the receipt and sufficiency of which are acknowledged, I knowingly and voluntarily on behalf of myself and my minor child do hereby agree to forever RELEASE, HOLD HARMLESS AND INDEMNIFY St. Joseph-on-Carrollton Manor, the Division of Youth & Young Adult Ministry, the Roman Catholic Archbishop of Baltimore and his successors, a Corporation Sole, and all their affiliate organizations, and respective agents, employees, officers, directors, volunteers, and any officials, referees, and other participants (the Released Parties) from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury (including death) sustained in connection with or arising out of my son/daughter's participation in the activity. By my signature below, I acknowledge that my child’s participation in the activity involves inherent risk of minor or serious injury, including permanent disability, death, and/or economic losses which might result from my child’s actions or inactions, the negligence of others, the inherent risks of the activity, the rules of play, the condition of the premises, or of any equipment used. I have voluntarily elected to allow my child to participate, and I fully understand, appreciate, and hereby assume all such dangers and risks. I understand that my child’s participation in said activities may require a minimum level of fitness for safe participation, and that the Released Parties do not screen, medically or otherwise, individuals that participate in the activity. I acknowledge that it is my sole responsibility to make certain that my child is physically fit and healthy enough to participate in the activity. I understand that the Released Parties do not provide medical treatment or medical, health or other insurance coverage for my child, however, I hereby grant permission for any staff member of the activity to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached. (Check one of the following:) ❐ I am covered by hospitalization and medical insurance under: policy # __________________ issued by __________________________ ❐ I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my son/daughter. I hereby grant permission to any staff member to provide the following over-the-counter drugs (or their generic equivalent) to my son/daughter if requested by my son/daughter (Check all that apply:) ❐ Tylenol/Acetaminophen ❐ Benadryl Diphenhydramine ❐ Advil/ Ibuprofen ❐ Imodium/ Antidiarrheal ❐ Neosporin/Antibody Ointment ❐ Pepto Bismol Doses of such drugs will be provided in accordance with the instructions contained on the drugs’ packaging. ADD any other medical information concerning medication, allergies, illness, etc.:______________________________________________ ADD any dietary restrictions:_________________________________________________________________________________________ Parents/guardians of participants are advised that photographs or digital recordings of participants may be used in publications, websites or other materials produced from time to time by the St. Joseph-on-Carrollton Manor, Division of Youth and Young Adult Ministry or the Archdiocese of Baltimore. (Participants will not be identified, however, without specific written consent.). Parents/guardians who do not wish their child(ren) to be photographed or digitally recorded should so notify an activity staff member. Please note that the Released Parties have no control over the use of photographs or digital recording taken by media that may be covering the event in which your child(ren) participate(s). I HAVE READ THE ABOVE RELEASE AGREEMENT, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGN-
ING IT, AND SIGN IT VOLUNTARILY.
Signature of Parent/Guardian Date ________________

Source: http://www.stjoesbuckeystown.org/wp-content/uploads/2012/03/DC-Pentecost-Pilgrimage-Permission-Slip.pdf