| St. Joseph Parish PARENTAL/GUARDIAN CONSENT FORM AND INDEMNITY AGREEMENT |
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| Event: | Location: | |||
| Date of Event: | Individual In Charge: | |||
| Time of Departure/Place: | Member
of St. Joes? |
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| Participant's Name: | Participant's Grade: | |||
| Birth Date: | Gender: | |||
| Parent/Guardian's Name: | Home Address: |
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| Work Phone: | Home Phone: | |||
| MEDICAL INFORMATION: | ||||
| Medication my child is taking at present: | ||||
|
Health
Condition: |
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| Family Health Plan carrier number (optional): | ||||
| Family Doctor (optional): | ||||
| Doctor's Phone (optional): | ||||
| Statement of Consent and Indemnity | ||
| grant permission for | ||
| (please print parent or guardian's name) | (child's name) | |
| to
participate in the above activity and I warrant that my child is in
good health. In consideration of my child's participation, I agree to
indemnify the parish/school and the Archdiocese of St. Paul/Minneapolis
by myself, my child or others that arises out of any behavior by my
child at the event/activity described above. I also agree to pay
reasonable attorney's fees or expenses incurred by the parish/school
and Archdiocese in defense of such a claim/law suit.
EMERGENCY
MEDICAL TREATMENT: In the event of an emergency, I give permission
to transport my child to a hospital for emergency medical treatment. I
wish to be advised prior to any further treatment by a doctor or
hospital. In the event of an emergency, if you are unable to reach
me at the above number, contact: |
||
| (name) | (phone number) | |
| As a parent or guardian, I agree to all of the above stated considerations and conditions. | ||
| (Signature) | (Date) | |