Parent/Guardian Information
Parent/Guardian 1 (Main contact for communication before and during this event.)
Parent/Guardian 2 or Other Emergency Contact
Medication Administration
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This child takes medication & will self-medicate. The child will bring all medications clearly labeled. I understand that all medication must be turned over to a supervising adult.
This child takes medication but is unable to self-medicate. The child’s parent/guardian/conservator will provide and dispense any and all needed medications.
This child takes no medication and will bring no medication with him/her.
Note about Medications: All Medical Information will be maintained in a strictly confidential manner. Should your child have an Emergency Injection Device (Epi-Pen), Diabetic Condition, Asthmatics with a rescue inhaler, or other special medical conditions, a separate sheet will need to be attached with a clear description as to the nature of the medical condition and any medication. This is important for situations where the youth is not able to self-administer these treatments and to communicate with Emergency Personnel. Ministry leaders, volunteers, and other parish staff are NOT trained to administer these types of emergency medications.
Consent to Participate and Liability Release
I / We, the parent(s)/guardian(s)/conservator(s) of the child listed on this form grant permission for my son/daughter to participate in all youth activities and functions. I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by my son/daughter. I/ We recognize the inherent risk associated with the various youth activities that my son/daughter will be participating in. I/ We agree on behalf of myself, my son/daughter named herein, my heirs, successors, and assigns to indemnify, defend, and hold harmless Our Lady of Angels Parish and the Roman Catholic Diocese of Dallas, their employees and/or volunteers from any and all claims (unless due to the Sole or Gross NEGLIGENCE of the Parish) for illness, injury, death, and the cost of medical treatment therewith, arising from or in any way connected with my son/daughter participating and/or attending the various youth programs and activities during this formation year noted above. In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this release, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, reasonable attorneys’ fees and expenses incurred by the prevailing party.
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Please select one option.
Authorization to Treat a Minor
I/We, are the parent(s) &/or guardians of the child listed above, a minor, and as such do hereby authorize Our Lady of Angels, its youth ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective throughout the specific event dates listed on this form. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I/we hereby release, defend and hold harmless the Parish and Roman Catholic Diocese of Dallas (Diocese), their officers, directors, agents, employees, volunteers, youth ministry leaders, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
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Media Consent & Social Media Communications
On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children and youth during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. As the State of Texas does not prevent audio or video recording or the photographing of children/youth For good and valuable consideration, I hereby grant to Our Lady of Angels Catholic Church the irrevocable and unrestricted right to make, use and/or publish any and all photographs, videos, and other images of me/my minor child or images in which Student may be included, now existing or hereafter made, in any case, with or without identifying Student for editorial, advertising, news, or any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. On behalf of myself and/or my child, I specifically waive all rights to privacy and confidentiality with respect to name, likeness, voice, photographs, images, video recordings, audio recordings and identifying information. I hereby release and agree to fully and unconditionally protect, indemnify, and defend Our Lady of Angels, the Roman Catholic Diocese of Dallas, and their respective officers, agents, and employees, (collectively, “Indemnitees”) and hold each Indemnitee harmless from and against any and all costs, expenses, attorney’s fees, claims damages, demands, suits, judgments, losses, or liability for injuries to property, injuries to persons (including Student) and from any other costs, expenses, attorney fees, claims, suits judgments, losses, or liabilities of any and every nature whatsoever arising in any manner, directly or indirectly, out of, in connection with, in the course of, or incidental to the use or publication of any photographs, videos, or other images of Student, REGARDLESS OF CAUSE OR OF THE JOINT, COMPARATIVE, OR CONCURRENT NEGLIGENCE OF THE INDEMNITEES. If you wish to opt out the participating child or discuss any part of this media release, please email Sheila Tullier at stullier@ourladyofangels.com.
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Participant Code of Conduct
Expectation: Every youth and adult will treat each other with respect because all are unique children of God. Participants are to immediately report any violation of this Code of Conduct or any other dangerous, improper or illegal conduct by anyone in our group, including adults, to a chaperone, whether or not the participant a victim or involved. If for any reason a participant cannot report such conduct to an adult leader, they will report it to my parents and to the Pastor or Parish Safe Environment Officer at the earliest possible opportunity. Dress Code: Participants will wear modest clothing to help project an understanding of the value as a child of God. No shirts with drug or sexual references. If an event includes swimwear, one piece or two-piece with a layered tank top is acceptable for female. No speedos for males. Participants will not go off alone, leave w/o permission, & will follow guidelines and directions of all adult leaders, including where they are needed to be. This event is not a date and participants will not show public displays of affection or close cuddling with other participants. Participants are to abide by all laws (property damage, weapons, firearms, stealing, no use of tobacco, alcohol, and illegal drugs, etc.) Parents may be financially responsible for damages to others property, facilities, or vehicles. Failure to comply with guidelines may lead to parental phone call, time out on event, or inability to go to future events.
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Electronic Signature for Agreements
Relationship to Participant
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Parent/Legal Guardian
