Form A -  Annual Youth Ministry Parent/Guardian/Conservator  Permission, Liability Waiver and Medical Information
Catholic Diocese of Fort Worth and/or the Parish of Good Shepherd Catholic Community
Annual Youth Ministry Parent/Guardians/Conservator Permission, Liability Waiver and Medical Information
Gender *

Parental/Guardian Information

Emergency Contact Information

Insurance Information

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:

Medications

NOTE: Please select one of the three boxes below.
Note: ┬áDO NOT CHECK ALL BOXES BELOW AS ONE MAY CANCEL OUT ANOTHER *
__________________________________________________________________________________________

Over-the-counter Medication Permission

NOTE: Please select one of the two boxes below.
 *
 YesNo
Non-aspirin pain reliever
Throat Lozenge
Decongestant
Antacid
Antihistamine

Specific Medical Information

Release/Indemntification Information

grant my permission  
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 2016 and continuing through the 31st day of May, 2017.  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 *


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