2023 Kickball Medical Release Form

Every player at the 2022 Kickball Tournament must complete this form or submit a physical copy before playing.

Code of Conduct, Medical & Media Release Form:

Before playing, every player must submit a signed form, either by using this electronic form or a physical copy.

Team Captains are responsible for ensuring every player on their team submits the form!

This is not a registration form. This form is to be used to give consent to participate and affirm the Code of Conduct, Medical, and Media Release statement. It should be submitted AFTER a player has registered and must be submitted by parent/guardian for minors (under 18). More information and registration at https://dohyouth.org/kickball
Click the image below if you want to print a physical copy:
Participant Information

This form should be submitted AFTER a person has registered. If you have not yet regsitered, please do so at https://web4u.forms-db.com/view.php?id=1452713
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Status
Are you serving as an Adult Chaperone for any minor (under 18)?

Are you serving as an Adult Chaperone for any minor (under 18)? Yes

See Kickball Handbook for details about serving as an Adult Chaperone at https://dohyouth.org/kickball
Are you serving as an Adult Chaperone from a church/school from the Diocese of Helena?

Are you serving as an Adult Chaperone from a church/school from the Diocese of Helena? Yes

Adult Chaperones from parishes/schools of the Diocese of Helena must be VIRTUS-certified.
Adult Chaperone Policy Statement

(Required of All Adult Chaperones; see Kickball Handbook for details at https://dohyouth.org/kickball)

Adult Chaperones from parishes/schools of the Diocese of Helena must be VIRTUS-certified. Adult Chaperones not from Diocese of Helena parishes/schools are expected to follow the safe environment/chaperoning policies of their respective church/group.

By signing below, I understand and agree to abide by all rules and policies of the 2022 Kickball Tournament and the respective Safe Environment/chaperoning responsibilities of the church/group for which I am serving as an Adult Chaperone.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Phone Phone - ### - ### ####
Email
Does Participant have any allergies, serious medical conditions, and/or is taking any medications that should be known in case of an emergency?

Does Participant have any allergies, serious medical conditions, and/or is taking any medications that should be known in case of an emergency? Yes
Please describe medical conditions:
Name of Your Team Captain Name of Your Team Captain First Last
Team Captain Email

A confirmation email will be sent to your Team Captain at this address to keep for their records.
Participant Code of Conduct, Medical Consent, & Media Release Statement:
I, the undersigned, hereby grant permission for the above named person (Participant) to participate in the 2022 Catholic Youth Coalition Kickball Tournament (Kickball) scheduled for Sunday, September 18 in Butte, MT, which may require transportation away from my home church. As a legal adult myself or the parent and/or legal guardian of Participant, I remain legally responsible for any personal actions taken by Participant. I agree on behalf of myself/my child named herein, or our heirs, successors, and assigns, to hold harmless and defend my parish/school and the Roman Catholic Bishop of Helena, Diocese of Helena (Diocese), adult chaperones, and representatives associated with Kickball, arising from or in connection with me/my child attending Kickball or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its directors and agents, and the Diocese, chaperones or its representatives for reasonable attorney’s fees and expenses arising in connection therewith.

I hereby warrant that to the best of my knowledge, I/my child is in good health, and I assume all responsibility for the health of me/my child. In the event of an emergency, I hereby give permission to transport me/my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital/doctor.

I/my child agrees to abide by all rules attached to Kickball. Specific behaviors that are not permitted include, but are not limited to: fighting, obscene language, offensive or revealing clothing, and the use/possession of tobacco, vaping products, alcohol, illegal drugs, and weapons. I also understand that if Participant violates any of the rules, Participant may be required to leave the activity at his/her own expense.

Event directors have the authority to prohibit video camera or other forms of image-recording devices, as appropriate, to prevent distractions or to protect against violating the privacy of participants. Violation of this policy may result in confiscation of such equipment for the duration of Kickball and/or dismissal from the event.

By signing this form I understand that a picture of myself/my child and/or work or projects created by myself/my child (e.g. still pictures, audio/video recording, etc.) may be published in print or online by my parish, school, Legendary Lodge, Diocese, The Foundation for the Diocese of Helena, Carroll College, or their agents to advance the mission and purpose of the Catholic Church. I also grant Diocese permission to share the information on this registration form with these or other individuals or entities to advance the mission and purpose of the Catholic Church.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

2023 Kickball Medical Release Form

2023 Kickball Medical Release Form

Code of Conduct, Medical & Media Release Form:

Click the image below if you want to print a physical copy:

Participant Information

Participant Code of Conduct, Medical Consent, & Media Release Statement: