Our lady of the Blessed Sacrament

PERMISSION FORM

Medical and Liability Release Information

(Please Print)

Participant Name:______Select one: Adult 18 & over Minor 17 & under

Parents or Legal Guardian Name: ______

Mailing Address: ______

Physical Address: ________

Email: ______Contact #’s: ______

Release of Liability

I understand that by participatingin the eventsorganized by theArchdiocese of Agana and Our Lady of the Blessed Sacrament Parish, known from this point forward as the Church, is a privilege. Prior to my participation in such events, I acknowledge that there are certain risks associated with these events, including, by way of example, physical injury due to activity-related or non-activity related accidents, due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

By signing this Medical Release and Liability Release Form, I expressly warrant that mychild named above or I (adult participant), am capable of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the child/Iparticipating in the events, whether such risks are known or unknown to me. I further release the Church, Our Lady of the Blessed Sacrament Parish, its ministers, leaders, employees, contracted employees, volunteers, agents and Bishop Baumgartner Memorial Catholic School from any claim that my child/I may have against them as a result of any injury or illness incurred during the course of participation in the events. This liability release is also intended to cover any and/or all claims that members of my child/my family, estate, heirs, representatives or assigns may have against the Church, Our Lady of the Blessed Sacrament Parish, or its ministers, leaders, employees, and volunteers. I further agree to indemnify and hold harmless the Church, Our Lady of the Blessed Sacrament Parish, its ministers, leaders, employees, contracted employees, volunteers, agents and Bishop Baumgartner Memorial Catholic School from any and/or all or any claims arising from participation in its events, or as a result of any injury or illness of the child or myself during such events.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where my child/I may be in need of first aid or emergency medical treatment, including anesthesia, as a result of an accident, illness, or other health condition or injury. I do hereby give permission for any agents of the church to seek and secure any needed medical attention or treatment for my child/I, including hospitalization. I also agree to pay any and/or all fees and costs arising from this action to obtain medical attention or treatment. I hereby give permission for any attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Emergency Contacts

1. Name: ______Relation: ______

Contact Numbers: 1. ______2. ______3. ______

2. Name: ______Relation: ______

Contact Numbers: 1. ______2. ______3. ______

Medical Insurance & Policy Number: ______

Primary Doctor Name & Contact Number: ______

Medical History

(Include special medical needs or concerns such as asthma, allergies, conditions, dietary needs, medications, etc.)

______

______

Other Information that leaders should know about the child or participant:

______

Please assure that each portion of this form is properly filled out. Failure to do so may result in your childor yourselfnot being able to attend or participate. Your child will be removed from the event premises if he/she is in possession of, but not limited to:

Illegal drugs;

Non-prescribed medication;

Alcohol;

Tobacco products (cigarettes, tobacco chew, etc.); or

Weapons (guns, knives, etc.)

Photo & Video Release (Check the appropriate box)

Ido /do not, grant permission for my child/Ito participate in any photo or videorelated to any and/or all events of the Church.

I agree to conduct myself in a Christian manner. I promise to respect God, respect myself, respect otherpeople and respect property. I understand that my agreement holds me responsible to these things and the consequences thereof. I agree toparticipate in the events of the Church, and that continuous participation in these events depends on my support of this agreement. By signingthis, I understand the terms and conditions mentioned and I am subject to be removed from the event premises if I break this agreement or partake in any of the following activities: possession of illegal drugs, non-prescribed medication, alcohol or tobacco products, possession of weapons, disrespect for authority, or any other inappropriate activity, verbal or non-verbal

Signature of Participant: ______Date: ______

For use if the Participant is under 18 years of age

Signature of Parent/Legal Guardian: ______ Date: ______

Print Name of Parent/Legal Guardian: ______

* Note: By affixing my signature, I understand and agree of ALL contents mentioned on page one (1) and two (2)and that this Medical Release & Liability Release Form is valid until formally revoked. You may email, mail or hand deliver a written notification to OLBS – Religious Education and Faith Formation Program, Attention Pale’ Marvin Bearis requesting to have this form revoked. A confirmation letter or an acknowledgement receipt by Pale’ Marvin will activate such request.

For Office Use Only:

Amount paid:______Date Paid:______Staff Name and initial:______

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135 ChalanKapuchinoAgana HeightsGU 96910

Tel: 671-472-6246 Fax: 671-477-1697

Revised 02/21/17