Permission, Release & Authorization to Seek Medical Treatment (Minors)

♦ Event & Event Dates: On going program; Youth Group (6th to 12th grade) 11/30/22-11/30/23

 

♦ Location(s): Immaculate Conception Church; 2nd & 4th Sundays, 6:00p.m. - 8:00p.m. 

 

♦ Activities Involved (specify nature of activities): Youth Group meetings, outdoor games, board games, faith formation talks, discussion, retreats, fundraising, service projeccts, Adoration, Mass, Confession, small group table conversations, inter-parish Youth Group sessions at both the Parish grounds and offsite, etc. 

 

♦ Contact person: Fr. Donnelly / Beth Martin

 

♦ Telephone No.: 440-428-5164

 

♦ NOTE: If you would like to download this form and complete, please click *here* to print.  After completing, please turn form into the Parish Office. 

Consent and Release
I, the parent or lawful guardian of, {state child's name below}, (the “child”), give permission for my child to participate in the Event, including without limitation the activities described above, (the “Event”) sponsored by Immaculate Conception Parish (the “Parish”). In exchange for and in consideration of the opportunity for my child to participate in the Event, I agree to the following:
Minor's Name
  •  
Parent / Guardian Additional Phone Number (if applicable) --
  •  
1. Event Scope. I understand what is involved in the Event and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Event. I further understand that my Child’s participation in the Event is purely voluntary and is a privilege.
2. Rules. I understand and agree that my child will be required to follow the Parish’s rules and cooperate with the person(s) in charge of the Event. I and my minor child agree to follow and comply with all safety protocols and procedures.
3. Photograph/Media Permission and Ownership. I consent and grant permission for the Parish, Diocese, and affiliated parishes and/or their agents to photograph, audio record, video or otherwise record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to use, display, publish, distribute, or alter the Recordings, or any part thereof, for any lawful purpose including, without limitation, on social media accounts, websites, in marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation. I further agree that the Recordings shall constitute the sole property of the Parish, Diocese, or affiliated parish taking the Recording.
4. Release and Hold Harmless. To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, hereby agree to release, discharge, and hold harmless the Parish, Diocese, affiliated parishes, and the Bishop / Administrator of the Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers (“Released Parties”) forever from and against any and all claims, lawsuits, damages, judgments, expenses including attorney’s fees, liabilities (of any nature or extent), demands, damages, cause of action of any nature and kind, known or unknown, which in any way arise out of or relate to my child’s participation in the Event (including without limitation any injury, loss, or damage to my child’s person or property or medical care provided in connection therewith), whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person) (the “Claims”).
5. Medical Insurance. I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or Diocese.
6. Medical Authorization. In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.
7. Miscellaneous. To the fullest extent allowed by applicable law, the Agreement shall be binding upon and inure to the benefit of the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. I, on my behalf and on behalf of my minor child, have the authority to release the Claims. This Agreement constitutes the entire agreement between the parties and supersedes any and all prior oral or written agreements or understandings between the parties concerning the subject matters of this Agreement. This Agreement may not be altered, amended or modified, except by a written document signed by both parties. The Released Parties, to the extent they are not parties to this agreement, are intended to be third party beneficiaries. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.
Name of Parent or Guardian
  •  
Date //
  •  
Home Address
  •  
Parent / Guardian Main Phone Number --
  •  
Name of Emergency Contact
  •  
Emergency Contact Phone No. --
  •  
Medical Information: Completed by Parent/Guardian
Child’s Name
  •  
Birth date //
  •  
Allergies
  •  
Chronic Conditions (e.g. epilepsy, diabetes)
  •  
Family Doctor
  •  
Phone No. --
  •  
Medications
  •  
  •  
 
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