Adult Permission, Release And Medical Power Of Attorney Form printable pdf download

ARCHDIOCESE OF CINCINNATI

ADULT PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY

(rev. 10-2014)

I, the undersigned will participate in the activity described on the Activity Information form and release from all

liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese

of Cincinnati and all parishes and schools within the Archdiocese (the “Archdiocese”), agents, representatives, volunteers,

and employees of the Archdiocese, from any and all liability, claims, judgments, cost and expenses, including attorneys’ fees,

arising out of any injury or illness incurred by me while participating in or traveling to or from the activity and further agree

not to bring or prosecute or allow to be brought or prosecuted (including but not limited to prosecution through subrogation)

in my name, any claims, lawsuits or actions against the Archbishop, and the officers, agents, representatives, volunteers and

employees of the Archdiocese,.

I further understand that my participation is purely voluntary and is a privilege and not a right. I elect to participate

in spite of the risks.

I agree to cooperate with the Archbishop or his agents in charge of the activity.

I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in

my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any

injury, illness or medical emergency occurs during the activity or related travel:

(i)

To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or

institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any

other emergency actions as our attorney shall deem necessary or appropriate for my best interest.

This power of attorney shall lapse automatically upon completion of the activity and related travel.

I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes,

website and office functions and use social media and technology to communicate to my child regarding ministry related

activities. (Facebook, texting, etc.)

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.

I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission,

Release and Medical Power of Attorney shall be effective and binding upon me and my own personal representative or estate,

assigns, heirs, and next of kin and that I have signed this agreement of my own free will.

Signature _____________

Date

Home Address

City

Zip

Place of Employment

Work Address

City

Zip

Phone No. (w)

(h)

Emergency Contact

Phone No. (w)

(h)

Adult Permission, Release And Medical Power Of Attorney Form

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