ST. PETER’S CATHOLIC CHURCH PERMISSION FORM

This form is for both parents of participating teens and adult leaders to complete to release all liability

from St. Peter’s Catholic Church and the Diocese of Toledo for all events and activities.

Parents please complete all information necessary under Youth and Parent

Adults please complete all information necessary under Adult

1. REGISTRATION + CONTACT INFORMATION

Name of Youth/ Adult Leader

Date of Birth

Gender

Male

Female

Grade

Name of Parent

Parent/ Adult Phone

Parent/ Adult Email

Youth Cell

Youth Email

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2. PERMISSION

The undersigned hereby state(s) that he/she is the parent or guardian of the above named Youth and have full legal responsibility for the Youth. The undersigned hereby grant(s) permission for the Youth to participate in all St. Peter’s activities. This Permission, Release, and Indemnification apply to all parts of participation in all activities, including transportation.

3. RELEASE AND INDEMNIFICATION

A. Release. The undersigned on behalf of the undersigned, the Youth, and the heirs, successors and assigns of the undersigned

and the Youth, 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 Toledo, the Parish and all current and former employees,

agents, clergy, officers and volunteers of the Diocese of the Toledo, arising from participation in all St. Peter’s activities.

B. Indemnification. The undersigned shall indemnify and hold harmless the Diocese of Toledo, the Parish, and all current and

former employees, agents, clergy, officers and volunteers of the Diocese of Toledo 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

participation in all St. Peter’s activities.

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4. 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

confidence.

Chronic Conditions (e.g. Epilepsy; Diabetes)

Allergic Reactions (e.g. Food, medications, plants, etc.)

Dietary Restrictions

Immunizations: Date of last tetanus/diphtheria immunization:

Any physical limitations?

You should be aware of these special medical conditions of the Youth:

B. Current Medication: The Youth is taking medication at present. The Youth will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:

C. Non-Prescription Medication Please check all of the following you wish to apply to your youth:

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

Non-prescription medication may be given to the Youth, if deemed appropriate.

My child may keep their non-prescription medication on their person and take it at their own discretion.

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5. EMERGENCY MEDICAL CONTACT AND TREATMENT

A. Emergency Contact Information

Medical Insurance Company

Policy #

Group #

Member’s Name

Insurance Phone

Family Doctor Name

Family Doctor Phone

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B. Emergency Medical Treatment

In the event of an emergency, the undersigned hereby give(s) permission to transport the undersigned or the Youth to a hospital

for emergency medical or surgical treatment. In the event of an emergency, if the undersigned cannot be reached at the above

numbers, contact:

Name

Relationship

Phone

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6. SIGNATURES

THE UNDERSIGNED HAS READ, UNDERSTANDS AND HEREBY AGREES TO AND ACCEPTS ALL

PROVISIONS IN THIS AGREEMENT

By checking this box I acknowledge that I agree to sign, consent to use an electronic signature, and promise that all the above information is correct to the best of my ability.

I AGREE

Youth's Signature

Date

Parent/Adult/Legal Guardian Signature

Date

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(This form will remain in effect until a request is made for it to be terminated)

ST. PETER’S CATHOLIC CHURCH PERMISSION FORM

1. REGISTRATION + CONTACT INFORMATION

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