PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Nativity Parish

Participant’s name: ______________________________________________________________

Birth date: ______________________________________________ Male/Female: __________

Parent/Guardian’s name: __________________________________________________________

Home address: _________________________________________________________________

Home phone: _______________________________________ Business phone: ____________

I, _________________________, grant permission for my child, _________________________, (Parent or guardians name) (child’s name)

to participate in the Holiday Lights in Lindenwood Park that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and volunteers from the Nativity Parish. A brief description follows:

Type of event: Lindenwood Park Holiday Lights Display

Destination of event: Lindenwood Park

1905 Roger Maris Drive Fargo, ND 58103

Individual in charge: Desirée Wilson

Date of event: December 14, 2011

Mode of transportation: Individual vehicles (of Desirée, Megan, Josie (group leaders))

As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Nativity Parish and the Diocese of Fargo, its directors and agents, chaperons, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment, and I agree to compensate the Nativity Parish and the Diocese of Fargo, its directors and agents, chaperons or representatives associated with the event for reasonable attorney’s fee and expenses arising in connection therewith.

Signature: ____________________________________________ Date: _________________

This document (both sides )should be kept with the chaperone attending the Youth Event!

 

(over)

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 that are applicable.)

Emergency Medical Treatment:

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name & Relationship:

______________________________________________________________________________

Phone: __________________

Family Doctor: ________________________________

Phone: ____________________

 

Family Health Plan Carrier: __________________________________

Policy #: _______________________________

Signature: _________________________________________________________

Date: ________________________

 

Medications:

 

My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows: _________________________________________________________

 

Signature: ____________________________________________________ Date: _______________________

 

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.

 

Signature: ____________________________________________________ Date: _______________________

 

I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

 

Signature: ____________________________________________________ Date: _______________________

 

Special Medical Information:

 

The Nativity Parish will take reasonable care to see that the following information will be held in confidence.

 

Allergic reactions (medications, foods, plants, insects, etc.): ________________________________________________________________________________________________________________________________________________

 

Immunizations: Date of last tetanus/diphtheria immunization:___________________________________________

 

Does your child have a medically prescribed diet? ________________________________________________________

 

Physical limitations? ___________________________________________________________________________

 

Is your child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

________________________________________________________________________________________________

Has your child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If  so, date and disease or condition: _____________________________________________________________________

 

You should be aware of these special medical conditions of my child: