Parental/legal Guardian Consent Form And Liability Waiver printable pdf download

PARENTAL/LEGAL GUARDIAN

CONSENT FORM AND LIABILITY WAIVER

Participant’s name _______________________________ DOB ___________

Parent/Guardian’s name ________________________________________________________

Home Address ________________________________________________________________

Home Phone _______________________

Cell Phone ________________________

I, _________________________________ grant permission for my child, __________________

to participate in this youth ministry event that requires transportation to a location away from the

parish site. This activity will take place under the guidance and direction of parish employees and/or

volunteers from ______________________________parish.

A brief description of the activity follows:

Type of event __________________________________________________

Destination of event _____________________________________________

Individual in charge ______________________________________________

Estimated time of departure _________________ return _________________

Mode of transportation to and from event _____________________________

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the

above named minor. (participant)

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold

harmless and defend ________________________,

its officers, directors, employees

(Name of Parish)

and agents, and the Catholic Diocese of Fort Wayne-South Bend, its employees and agents,

chaperons, or representatives associated with the event, from any claim arising from or in connection

with my child attending the event or in connection with any illness or injury (including death) or cost of

medical treatment in connection therewith, and I agree to compensate the parish, its officers,

directors and agents, and the Catholic Diocese of Fort Wayne-South Bend, its employees and agents

and chaperons, or representative associated with the event for reasonable attorney’s fees and

expenses which they may incur in any action brought against them as a result of such injury or

damage, unless such claim arises from the negligence of the parish/diocese.

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.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport

my child to a hospital for emergency medical or surgical treatment. I 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 at the above numbers contact ______________________________________.

____________________________________

____________________

Signature

Date

Parental/legal Guardian Consent Form And Liability Waiver