Welcome to the Archdiocese Of Denver Liability Waiver Generator



Group Information

Please check that the below information is correct and click ‘Next’.


*Select who you are and click ‘Next’ .

Participant Information


Activity Information


Father/Male Guardian


Mother/Female Guardian


Emergency Contact


Health Information(please have your insurance card with you at all times)


* Date of last tetanus/flu immunization:
  Yes
  No

This field is required.

This field is required. Please make sure file size is not more than 5Mb.

*Does participant have a medically prescribed diet?
   Yes
   No

This field is required.

This field is required.

* Has Participant recently been exposed to contagious disease or conditions, such as mumps, measles, flu, chickenpox, etc.? If so, date and disease or condition:
Mumps
Measles
Flu
Chicken Pox
   No

This field is required.

This field is required.

* I want to be contacted in the event it comes to the attention of the parish/school/organization, its officers, directors and agents, and the Archdiocese of Denver, chaperones, or representatives associated with the activity that Participant experiences symptoms such as headache, vomiting, sore throat, fever, diarrhea, etc.
  Yes
  No

This field is required.

* I/We hereby grant permission for the following non-prescription medication (non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup, etc.) to be administered to the Participant, if deemed appropriate.
  Yes
  No

This field is required.

This field is required.

* Or No Medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
  Yes
  No

This field is required.

* Food Allergies (select all that apply)
Milk
Egg
Wheat
Soy
Fish
Shell Fish
Peanuts
Tree Nuts
Gluten
Dairy
Diabetic Needs
Low Sodium
Other Allergies (Allergic Reactions)
No Allergy

Please select no allergy option in case you don't have any allergy.

This field is required.


Review the below information before proceeding.


Attendee Type


Type:

Personal Information


Email:

Title:

First Name:

Last Name:

Birthday:

Sex:

T-Shirt Size:

Address1:

Address2:

City:

State:

Zip:

Home Phone:

Cell Phone:

Business Phone:

Activity Information


Type of Event:

Location:

Individual Incharge:

Duration:

Transport Mode:

Parent/Male Guardian


First Name:

Last Name:

Email:

Home phone:

Cell phone:

Parent/Female Guardian


First Name:

Last Name:

Email:

Home phone:

Cell phone:

Emergency Contact


First Name:

Last Name:

Contact:

Relationship:

Phone(Day Time)

Phone(Night Time):

Health Information(please have your insurance card with you at all times)


Family Physician:

Physician Phone:

Insurance Co:

Insurance ID#

Insurance Group#

Cardholder's Name:

Policy #:

Date of last tetanus/flu immunization:

Participant is taking medication at present.

  Yes
  No
Does participant have a medically prescribed diet?
  Yes
  No

Prescribed Diet

Has Participant recently been exposed to contagious disease or conditions, such as mumps, measles, flu, chickenpox, etc.? If so, date and disease or condition:

Mumps
Measles
Flu
Chicken Pox
No

Contagious Disease/Condition and Date

I want to be contacted in the event it comes to the attention of the parish/school/organization, its officers, directors and agents, and the Archdiocese of Denver, chaperones, or representatives associated with the activity that Participant experiences symptoms such as headache, vomiting, sore throat, fever, diarrhea, etc.

  Yes
  No

I/We hereby grant permission for the following non-prescription medication (non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup, etc.) to be administered to the Participant, if deemed appropriate.

  Yes
  No

Non Prescribed Medicines

Or No Medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.

  Yes
  No
Food Allergies (select all that apply)
Milk
Egg
Wheat
Soy
Fish
Shell Fish
Peanuts
Tree Nuts
Gluten
Dairy
Diabetic Needs
Low Sodium
Other Allergies
No Allergy

Allergic reactions (medications, foods, plants, insects, etc.):

Current Medication and Dosage (prescription and over the counter):

Medical History/Chronic Medical Problems (e.g. diabetes, epilepsy):

Any physical limitations?

Other special medical conditions

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Name of Minor ("Participant") Home Address Home Phone: Business Phone: Parent(s) Gaurdian(s) Name(s): , I/We , grant permission for my/our child to participate in this parish/school/organization activity. This activity will take place under the employees and/or volunteers guidance and direction of

A brief description of the activity follows:
Type of event:
Location(s):
Individual(s) in charge:
Duration of Activity:
Mode of transportation to and from event:

As parent(s) and/or legal guardian(s), I/we remain legally responsible for any personal actions taken by the above-named Participant.
I/We further agree to defend, indemnify and hold harmless the Parish/School/Organization and the Archdiocese of Denver as well as any of its affiliated agencies and their respective agents, directors, officers, employees, and volunteers from any and all claims or demands made for damage, loss, illness or injury to the above-named Participant.

MEDICAL MATTERS

The Parish/School/Organization will take all reasonable and prudent care to see that confidentiality regarding the following information is maintained.
I/We hereby warrant that to the best of my/our knowledge, my/our child is in good health, and I/we assume all responsibility for the health of my/our child. I/We understand and acknowledge that any medical expenses related to illness or injury to my/our child are not covered by any insurance program maintained by the Parish/School/Organization or the Archdiocese of Denver, and that I/we am/are responsible for such expenses.

Emergency Medical Treatment:

In the event of an emergency, I/we hereby give permission to transport my/our child to a hospital for emergency medical or surgical treatment. I/we wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me/us at the above numbers,

First Name:
Last Name:
Emergency Phone(s):
Relationship:
Name of Minor (“Participant”):
Sex:
Birth Date:
Name of Parent(s)/Guardian(s) ,
Family doctor:
Phone:
Family Health Carrier Plan:
Policy#:
Allergic reactions (medications, foods, plants, insects, etc.):
Immunizations: Date of last tetanus/flu immunization:
Does Participant have a medically prescribed diet?
Any physical limitations?
Has Participant recently been exposed to contagious disease or conditions, such as mumps, measles, flu, chickenpox, etc.? If so, date and disease or condition:
Other special medical conditions:

Medications:

Participant is taking medication at present.
  Yes
  No

It is Participant’s responsibility to bring all necessary medications, and to ensure they are clearly labeled. Instructions from the Participant’s family physician for these medications must be attached to this form. The instructions must include the name, concise dosing directions, purpose of, and proper storage of and for all medications.

NOTE  Parish/School/Organization staff and volunteers WILL NOT administer ANY medications requiring the use of a syringe or other needle delivery system. Alternate accommodations for must be made for these circumstances and the parish/school/organization fully informed of the nature of such accommodations.

Notice  I want to be contacted in the event it comes to the attention of the parish/school/organization, its officers, directors and agents, and the Archdiocese of Denver, chaperones, or representatives associated with the activity that Participant experiences symptoms such as headache, vomiting, sore throat, fever, diarrhea, etc.
  Yes
  No

I/We hereby grant  permission for the following non-prescription medication (non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup, etc.) to be administered to the Participant, if deemed appropriate.
  Yes
  No

Non Prescribed Medicines


OR: No medication  of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
  Yes
  No

FIELD TRIP ADULT LIABILITY WAIVER

Each adult participant, including group leaders and chaperones, must sign this form.

I, , agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend Spirit of Christ, The Archdiocese of Denver, and its officers, directors, agents, employees, or representatives associated with the field trip from any and all liability claims, loss or damage arising from or in connection with my participation in the field trip.

In the event that I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.


Please advise the doctors that I have the following allergies:

In case of an emergency and for permission for treatment beyond emergency procedures, please contact:

Name:  
Relationship to me: 
Daytime Phone:  
Night Time Phone:
Health Insurance Carrier: 
Insurance ID Number:
Insurance Policy Number:

To sign,left-click anywhere in the box above and hold down while using your mouse or trackpad to draw your signature.Click the 'Clear Signature' button to start over.