CCYM Emergency Medical Consent and Permission Form

Event: Steubenville Youth Conference
Location: Franciscan University-Steubenville, OH
Dates: June 14-16, 2019
Transportation: Coach Bus

Name of Conference Attendee Name of Conference Attendee First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Emergency Contact Emergency Contact First Last
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Allergies
Medications (including frequency, dosage, etc.) Certain medications may need to be given to a chaperone prior to departure.
Special Needs (asthma, dietary, etc.)
Physician's Name Physician's Name First Last
Physician's Phone Physician's Phone - ### - ### ####
Health Insurance Company
Policy Number
In the event my child is injured or requires immediate and/or emergency care and I cannot be contacted, I authorize the event leaders to act for me according to his/her best judgment (including treatment and/or transportation to area medical facilities). I also authorize area hospital medical personnel to act on my behalf in the event of an emergency and I cannot be contacted.

I know that all possible care and safely will be provided for my child, therefore in case of an accident, to the fullest extend allowed by law, I agree to RELEASE FROM LIABILITY, AND TO INDEMNIFY AND HOLD HARMLESS, the Archdiocese of Washington, Sacred Heart Parish, La Plata; St. Catherine Parish, McConchie; St. Ignatius Parish, Hilltop; priests, deacons, teachers chaperones or representatives associated with the above event

I also agree to release from liability the Archdiocese of Washington, Sacred Heart Parish, La Plata; St. Catherine Parish, McConchie; St. Ignatius Parish, Hilltop; priests, deacons, teachers chaperones or representatives associated with the above event from any liability resulting from injury from, damage to - or damage caused by - my child at the event facility.

The Archdiocese of Washington, Sacred Heart Parish, La Plata; St. Catherine Parish, McConchie; St. Ignatius Parish, Hilltop; priests, deacons, teachers chaperones or representatives associated with the above event assume no liability for lost, stolen or damaged personal property.

I give hereby grant permission to the Archdiocese of Washington, Sacred Heart Parish, La Plata; St. Catherine Parish, McConchie; St. Ignatius Parish, Hilltop; to use any photographs and quotations taken of my child during this event to assist in community awareness, educational efforts, related public relations purposed that may include brochures, posters, website, official social media, and print media.
Parent Signature below.

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.
Date Date / MM / DD YYYY