PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Please fill out the following form.

I grant permission for this participant to participate in this event that requires transportation to a location away from the parish/school site. This activity will take place under the guidance and direction of parish/school employees and/or volunteers from.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named participant.

I agree on behalf of myself, this participant named herein, or our heirs, successors, and assigns, to hold harmless and defend the

Roman Catholic Bishop of Fall River, Corp Sole, its officers, directors, employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with this participant attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, the Roman Catholic Bishop of Fall River, Corp Sole, its officers, directors, employees and agents, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school. MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, this participant is in good health, and I assume all responsibility for the health of this participant.

Medical Treatment: In the event that this participant becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be contacted at the following phone numbers:

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport this participant to a hospital for emergency medical or surgical treatment. I wish to be advised by the hospital or doctor prior to any further treatment. In the event of an emergency, if you are unable to reach me at the provided numbers, contact:

Medications: This participant has been prescribed medication during school hours that may be required to be given during the event. The medication may be administered by a school representative who has been trained and authorized to administer the medication by the school nurse. I am aware that this may not apply to all medications (ex. Insulin, seizure medication, glucagon, etc.), which cannot be delegated to nonmedical personnel.

Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence.

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