PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
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.
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,
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:
Participant is taking medication at present.
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.
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.
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.
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.
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:
Night Time Phone:
Health Insurance Carrier:
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