Waldameer

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Holy Sepulcher and Saint Kilian Parishes

Youth Ministry Off-Site Activities Permission Form

and Medical Release Form

*Yes, we know it is repetitive and we apologize BUT Diocesan guidelines require a NEW form for EACH off-site event for each participant.

One form per participant per event.
If you have any questions or need additional information please contact

Andrea Wheeler at awheeler@saintkilian.org or call 724-625-1665 ext. 2134

Participant Information

Family's home parish*

Name of participant *

First Name

Last Name

Birth date*

Age*

Gender*

Student School*

Select Grade*

Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 2023 Grad

Student Email*

Student's Cell Number

Street Address*

City*

State*

Zip Code*

Life Teen Event Selection

Please select the event you are registering for today and providing consent.*

Waldameer 2023

Per the Diocese, one form per participant per event.

Parent / Guardian Information

Name*

First Name

Last Name

Relationship to the Participant*

Mother Father Legal Guardian

Must be one of the three to authorize minor to attend this event.

Email*

Best Phone Number to Reach You at During This Event*

I/we, the parents or guardians of the above mentioned child, for myself/ourselves and for my/our child, give permission for my/our child to participate in the above selected event. *

Yes, I agree

I would like to chaperone this event. (Clearances are on file with SK/HS)*

Yes, I'd love to help! Not at this time.

Indemnification/Medical Authorization

INDEMNIFICATION In consideration of the Saint Kilian and Holy Sepulcher Youth Ministry’s agreement to allow my/our child to participate in the and intending to be legally bound, hereby, I/we agree to indemnify and hold harmless, the Saint Kilian and Holy Sepulcher Youth Ministry, the Catholic Institute of Pittsburgh, their agents, successors and legal representatives, against any loss from any and all claims, demands, and actions at law or in equity that may hereafter at any time be brought by myself/ourselves, my/our child, or anyone of his/her behalf, for the purpose of enforcing a claim for damages because of any injury or property damages sustained by my/our child as a result of, or in any way related to his/her participation in the above mentioned event. I/we also give permission for my/our child’s pictures to be published in the parish directory, bulletin, or on the website. MEDICAL AUTHORIZATION In the event of any injury or illness to my/our child during his/her participation in this program, I/we hereby give my/our permission for the necessary medical treatment to be given to my/our child. I/we, for myself/ourselves, for my/our child, our respective heirs, and my/our respective legal representatives, do hereby indemnify and hold harmless any representative of the Saint Kilian and Holy Sepulcher Youth Ministry and from any and all claims, demands, and courses of action of whatever kind and nature for their actions taken pursuant to this authority. I/we agree that in case of injury to my/our child, I/we will apply my/our hospitalization and/or accident insurance toward payment of the expenses incurred and will not look to Saint Kilian and Holy Sepulcher, the Catholic Institute or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury related costs.*

YES, I agree to this indemnification/medical authorization.

Insurance Company*

Policy #*

Consent to Treat

I/We, the undersigned parent(s)/guardian of the participant named above, a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may so arise, or any hospitalization necessary.*

YES, I authorize treatment. NO, I do not authorize treatment.

Emergency Contact

Emergency Contact Name (if parent/guardian is not available:)*

First Name

Last Name

Emergency Contact Phone*

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.

1) Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. My child will be responsible to administer his/her own medication.*

YES NO

2) I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable.*

YES NO

3) No medicating of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.(Click Yes only if you do not want any medications administered to your child.)*

YES NO

Please list any known allergies

Please list any physical limitations

Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting? If yes, please explain below:

Does your child have any other special needs? If yes, please explain below:

Payment and Signature

Total Cost: $

Paypal Multiplier

Name on Credit Card*

First Name

Last Name

Credit Card*

Signature: By signing below you authorize that all consents and statements completed above are true and valid. All consents are valid for the duration of this event only while your minor is in the care of Holy Sepulcher and Saint Kilian Parish.*

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