Annual Medical Information Form (Page 2 of 2) in pdf

If you would like your youth to participate in parish activities, please sign and return the following statement of consent

and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may

result from any personal actions taken by your youth.

In consideration for the opportunity for my child to participate in parish activities, and fully recognizing that such an

undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby

release,

absolve,

indemnify

and

agree

hold

harmless

the

Diocese

Pensacola-Tallahassee

and

______________________________Parish, and their employees, agents, volunteers, and other persons acting on their

behalf.

Neither the Diocese of Pensacola-Tallahassee, _____________________________ Parish, nor said agents,

employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or

indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it

voluntarily and with full knowledge of its significance.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of

Pensacola-Tallahassee, and ______________________________ Parish, through its authorized representatives, to

transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We

additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical

treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release

the Diocese and ________________________________Parish, and their authorized representatives from any and all

claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be

advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.

Finally, I/we hereby give permission for the Diocese of Pensacola-Tallahassee and any of its affiliated organizations,

including, but not limited to The Florida Catholic, to use the name of my child and/or his/her photograph for promotional,

news, or public relations purposes in print and/or electronic media.

________________________________________________________

Print Parent/Guardian Name

________________________________________________________

___________________

Signature of Parent/Guardian

Date

This form is to be kept at the parish and renewed annually

Revised 8/2007

Annual Medical Information Form

Annual Medical Information Form Page 2