8/7/2019 Little Flower Retreat Liability Waiver
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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
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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:
________________________
