Form A (2019-2020) Youth Form

Form A - Annual Youth Ministry Parental Liability Waiver, Permission Waiver and Medical Information

Catholic Diocese of Fort Worth and/or the Parish of Good Shepherd Catholic Community

Youth Participant's First and Last Name *

Birthdate (mm/dd/yyyy) *

Gender *

Female

Male

Grade 2019-2020 *

School *

T-shirt size *

Parental/Guardian Information

Parent/Guardian Name: *

Home Address *

City *

State

Zip *

Home Phone (xxx) xxx-xxxx

Cell Phone (xxx) xxx-xxxx *

Texting: *

Email *

Emergency Contact Information

Emergency Contact Name (other than PARENT/GUARDIAN): *

Relationship to Youth Participant *

Emergency Phone (xxx) xxx-xxxx Must be different from parent cell phone *

Texting: *

Insurance Information

Is the Participant insured? *

If yes, please fill out the information below FROM THE PARTICIPANTS Insurance Card. If you do not have insurance put none in the boxes below:

Name of Policy Holder (whose name is the policy in) *

Insurance Carrier/Name of Insurance Co: *

Policy Number *

Insurance ID Number *

Claim Address/City/State/Zip *

Customer Service Phone Number *

Medications

NOTE: Please select one of the three boxes below.

Note: DO NOT CHECK ALL BOXES BELOW AS ONE MAY CANCEL OUT ANOTHER *

This child takes no medication and will bring no medication with him/her.

This child takes medication/s and will self-medicate. The child will bring all such medications necessary, and such medications will be clearly labeled. I understand that the child will be required to turn all medications over to a supervising adult designated to keep medications. I further understand that it will be this child's responsibility to present himself/herself at a location designated for returning medications to this child at the frequencies/times listed below. I understand that the adult to whom this child surrenders the medications has no medical training and this adult will not measure dosages. This child will return the medications to the adult after he/she self-medicates. At the conclusion of the event it will be this child's responsibility to pick up remaining medications, if any, at the self-medication designated location. Names of the medications and exact dosage and frequencies/times are as listed below*: (you may attach a sheet to this form if you need more space just make sure to sign and date it as well).

This child takes medication but is unable to self-medicate. The parent/guardian/conservator will provide & dispense any & all needed medications.

*Please list Names of medications and exact dosage and frequencies/times.

__________________________________________________________________________________________

Over-the-counter Medication Permission

NOTE: Please select one of the two boxes below.

*

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

I grant permission for the following nonprescription medications to be given to this child in the recommended dosage on the medication bottle.

	Yes	No
Non-aspirin pain reliever	Yes	No
Throat Lozenge	Yes	No
Decongestant	Yes	No
Antacid	Yes	No
Antihistamine	Yes	No

Specific Medical Information

1. Allergic reactions (medication, foods, plants, insects, etc.)

2. Any physical limitations

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

4. Please describe any other special medical or non-medical conditions of this child

Release/Indemntification Information

I *

grant my permission

for *

to participate with the various programs and activities of the Diocese of Fort Worth and/or the parish of Good Shepherd Catholic Community beginning the 1st day of June 2019 and continuing through the 31st day of May, 2020. These various programs and activities will take place under the guidance and direction of employees and/or volunteers from the parish of Good Shepherd Catholic Community and/or the Diocese of Fort Worth. This permission and liability waiver will be kept on file and will accompnay the child on any and all programs and activies of the Diocese of Fort Worth and/or the parish of Good Shepherd Catholic Community. A separate FORM B Consent to Participate and Consent to Emeregency Medical Treatment must be filled out and turned in to accompany this form per each program and/or activity.

I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by the participant name above.

I agree on behalf of myself, my son/daughter/participant named herein, our/his/her heirs, successors, and assigns to hold harmless, the Diocese of Fort Worth, the Bishop and his successors, employees, agents, volunteers, the Parish, its employees and volunteers from any and all claims (unless due to the negligence fo the Diocese and/or Parish) for illness, injury, death and the cost of medical treatment therewith, arising from or in any way connected with my son's/daughter/participant's attending the various programs and activities during the dates named above.

In the event any legal action is taken by either party againest the other party to enforce any of the terms and conditions of this agreement, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonalbe court costs, reasonable attorneys' fees and expenses incurred by the prevailing party.

Promotional Release

I also consent to the use of any videotapes, photographs, slides, audiotapes, or any other visual or audio reporduction (in perpetuity unless otherwise revoked by me in writing and delivered to Good Shepherd Catholic Community and by certified mail, retrun receipt requested, to: The Catholic Center, 800 West Loop 820 South, Fort Worth, TX 76108, Attn: Director of Youth Ministry and Adolescent Catechesis) in which my son/daughter may appear by the Diocese of Fort Worth. I understand that these materials, including websites and social media sites, are being used for promotion of the youth ministry of the Diocese of Fort Worth which may include recruitment and fundraising efforts.

Social Media Release

The Diocese of Fort Worth utilizes today's technology in a positive way to reach out to the youth of the Diocese, including Facebook, email and other social media. We may remove any content deemed inapporopirate. All communication with any youth through social media programs by anyone representing the Diocese may be made available to any parent upon request. If you do not allow your son/daughter to text, Facebook, or use other social media, there will be no expectation that they do so in order to participate in certain youth ministry events. However, the Diocese cannot guarantee that photos, videos or other communications of your son/daughter from diocesan and/or parish events will not be uploaded to a social media site.

Self Protection Program

Parents: Our ministry with your child is a sacred trust. Because of this, we are committed to following the Diocesan mandate to provide classroom training to teach of our children and youth on how to protect themselves from sexual abuse. This mandate originated with the United States Conference of Catholic Bishop's Charter for the Protection of Children and Young People. In the Diocese of Fort Worth, this program will be integrated into the religious education (Faith Formation) classes each year in all parishes. Lessons that are age appropriate have been developed for PreK through grade 12 and will be taught annually with your approval. Parents are welcome to attend these classes.

My child may participate in the Child Self-Protection Program *

Yes

No

To the best of my ability, everything I have stated here is true and accurately reflects my wishes.

Parent/Guardian/Conservator Name *

Date *

*

By checking this box and typing your name above, you have agreed that this is your electronic signature.

I am registering for *

Parish Service Day

Family Mission Trip

Lifelong Faith Formation