CHRIST THE KING YOUTH GROUP

MEDICAL RELEASE FORM/CONSENT AND WAIVER OF LIABILITY

Youth Group Meetings and Events at Christ the King Catholic Church

Please complete this form using blue or black ink, and print

PARTICIPANT’S NAME: ______

(FIRST) (MIDDLE) (LAST)

HOME ADDRESS : ______

______

(Include City and Zip Code)

Names of Parents/Guardians: ______

Home Phone: ______Work Phone: ______

Number to call for emergency: ______

Cell Phone(s): ______

Insurance Company: ______

Policy Holder’s Name: ______

Relationship to Policy Holder:______

Policy Number: ______

In case of an emergency and parents cannot be reached, contact:

(Name) (Phone Number(s)) (Relationship)

Medical Information (Attach a separate sheet if necessary.)

1) List all allergies your child has: ______

2) List all medications your child will have with him/her and directions for taking it: ______

In the event of an emergency, I hereby give authority to the accompanying adults (Patti Smith or Charles Goolsby), to authorize emergency medical treatment for my child. I understand that an attempt to notify me will be made before treatment is authorized.

PARENT/GUARDIAN SIGNATURE:

______DATE______

I/We hereby grant permission for our son/daughter ______to participate in the Youth Group meetings and events at Christ the King Catholic Church. I understand that these events will take place under the guidance and direction of parish volunteers who have completed the Diocesan-mandated Virtus training for the protection of children.

My/Our understanding of the event is:

Event:Meetings, lock-ins, retreats and/or workdays at Christ the King Catholic Church.

Individuals in Charge:Patti Smith and Charles Goolsby and other Virtus-trained adults

Date(s)/Time(s): Meetings: Sunday evenings from 4:30 p.m.-6:00 p.m. August 2007-April 2008; other dates to be announced

Mode of Transportation: Each participant must arrange for his or her own transportation. If a person younger than 18 years of age is going to provide transportation for another child younger than 18 years of age who is not a member of his/her family, the passenger must have the written permission of his/her parents to ride with the youth driving, and the driver must have the written permission of his/her parents to transport the passenger.

As parent/legal guardian, I remain legally responsible for any personal action(s) taken by my child. I hereby state that I/we will hold harmless the Parish of Christ the King Catholic Church and the Diocese of Richmond, as well as their officers, directors, agents, chaperones, or representatives associated with this event, from any injury arising from or in connection with my/our child attending this event, including but not limited to accidents/emergencies, and/or the exposure to reckless conduct of other persons. I hereby expressly waive any claims I/We may have or ever have against the hosts and chaperones, the parish of Christ the King, and the Diocese of Richmond arising from, related to, or associated with my/our child’s participation in these events.

PARENT/GUARDIAN SIGNATURE(S):

DATE:______