Little Flower Retreat Liability Waiver

  • Published on
    08-Apr-2018

  • View
    215

  • Download
    0

Embed Size (px)

Transcript

  • 8/7/2019 Little Flower Retreat Liability Waiver

    1/2

    PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

    Participants Name: _____________________________________ Birth Date: ___________________

    Parent/Guardians Name: _____________________________________________________________

    Home Address: ___________________________ E-mail Address: _____________________________

    Home Phone: ______________________________ Cell Phone: ______________________________

    I, (name of parent or guardian) ____________________________________, grant permission

    for my child (name of child) __________________________________, to participate in the Life Teen Annual

    Retreat from May 20, 2011 at 5:00 pm to May 22, 2011 at 6:30 pm at the Sacred Heart Spirituality Center inNewton, NJ (the event). I understand that my child may be driven to and from the Sacred Heart SpiritualCenter from Church of The Little Flower in accordance with the guidelines outlined by the Roman Catholic

    Archdiocese of Newark on transportation of minors.

    For value received, I agree on behalf of myself, my childs other parent/guardian if

    known or living (name of parent) __________________________________ my child named herein, or ourheirs, successors, and assigns, to hold harmless and defend Church of The Little Flower, its officers, directors,agents, representatives, volunteers, employees, or chaperones associated with the event, arising from or in

    connection therewith, and I agree to compensate Church of the Little Flower, its officers, directors, agents,representatives, volunteers, employees, and chaperones associated with the event for reasonable attorneys

    fees and expenses arising in connection therewith.

    Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all

    responsibility for the health of my child. Of the following statements pertaining to medical matters, sign onlythose in accordance with your wishes.

    Emergency Medical Treatment: In the event of an emergency, I hereby give permission to Church of the LittleFlower, its officers, directors, agents, representatives, volunteers, chaperones, or representatives associatedwith the event, to transport my child to a hospital for emergency medical or surgical treatment. I wish to beadvised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable

    to reach me at the above numbers, contact:

    Name and Relationship : ________________________________________________________

    " Telephone: __________________________________

    Family Doctor : _______________________________________________________________

    " Telephone: __________________________________

    Family Health Plan Carrier : _____________________________________________________

    " Policy Number: __________________________________

    (1) Signature: __________________________________________ Date: ________________________

    PLEASE TURN OVER AND COMPLETE THE BACK OF THIS FORM

    Church of The Little FlowerBerkeley Heights, New Jersey

  • 8/7/2019 Little Flower Retreat Liability Waiver

    2/2

    Other Medical Treatment: In the event it comes to the attention of Church of The Little Flower, its officers,

    directors, agents, representatives, volunteers, employees, chaperones or representatives associated with theevent, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want

    to be called REGARDLESS of the Time, etc.

    (2) Signature: __________________________________________ Date: ________________________

    Medications: My child is taking medication at present. My child will bring all such medications necessary, andsuch medications will be well-labeled. Names of medications and concise directions for seeing that the childtakes such medications, including dosage and frequency of dosage are as follows:

    ___________________________________________________________________________________

    (3) Signature: __________________________________________ Date: ________________________

    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.

    (4) Signature: __________________________________________ Date: ________________________

    I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to begiven to my child, if deemed advisable.

    (5) Signature: __________________________________________ Date: ________________________

    Specific Medical Information: Church of The Little Flower will take reasonable care to see that thefollowing information will be held in confidence.

    Allergic reactions (medications, foods, plants, insects, etc) ____________________________________

    Immunizations (date of last tetanus/diphtheria) _____________________________________________

    Medications child currently takes ________________________________________________________

    Does child have a medically prescribed diet? ______________________________________________

    Any physical limitations? ______________________________________________________________

    Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking,

    bedwetting, fainting? _____________________

    Has child been recently exposed to contagious disease or condition, such as mumps, measles, chicken

    pox, etc? If so, what condition? _________________________________________________________

    You should also be aware of these special medication conditions of my child:____________________________________________________________________________________

    I fully understand the consequences of the foregoing statements and sign this PARENTAL/GUARDIAN

    CONSENT FORM AND LIABILITY WAIVER knowingly, freely, and willingly.

    YOUR SIGNATURE MUST APPEAR BELOW OR YOUR CHILD WILL NOT BE

    PERMITTED TO ATTEND THE EVENT

    (6) Signature: __________________________________________ Date: ________________________

Recommended

View more >