St. Brigid of Kildare Church Middle School Youth Ministry

Parent / Guardian Consent and Liability Waiver

Participant's Name_____________________________

Birthdate__________     Sex__________     Grade__________

Participant is____a Member of St. Brigid Parish  ____Guest of a St. Brigid Student

Parent's / Guardian's Name___________________________________________

Home Address____________________  Home Phone_______________  Emergency Phone__________________

I, ____________________, grant permission for my child_______________ to participate in this diocesan / parish Youth Ministry event that requires transportation to a location away from parish sites.  This activity will take place under the guidance and direction of diocesan / parish employees and / or volunteers from St. Brigid.

Event: 

Date:                                                          Departure Time:                                               Return Time:

Type of Transportation:

Person(s) in Charge:

If transportation is required during the event, I give permission for my child, __________ to ride with a driver 21 years or older.  As a parent / guardian, I remain legally responsible for any personal actions taken by the above named minor participant.

I agree, on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Brigid of Kildare Church, its officers, directors, agents and the Diocese of Columbus, chaperones or representatives associated with the event from any claim or damages to any person or property arising from our connection with my child attending the event or in connection with any illness or injury or the cost of medical treatment in connection therewith, and I agree to compensate the Parish, its officers, directors, and agents and the Diocese of Columbus, chaperones, or representatives associated with the event for reasonable attorney's fees and expenses arising from connection therewith.

PARENT / GUARDIAN SIGNATURE_________________________  DATE__________

PARTICIPANT SIGNATURE_______________________________  DATE___________

MEDICAL INFORMATION

TO BE COMPLETED BY PARENT / GUARDIAN (Please Print)

Participant Name_________________________  Birthdate__________  Sex_____

Allergies__________________________  Medications Currently Taking_________________________________

Chronic Medical Conditions (e.g. Asthma, Diabetes, Epilepsy, etc.)_____________________________________

Medical Insurance Company_________________________ 

Policy / Group #________________  Member's Name________________  Home Phone:__________ 

Emergency Number(s)_______________  Family Physician_______________  Phone Number____________

Code of Behavior

1.  Participants must stay for the entire event unless accompanied by a parent or guardian.

2.  No foul language, drugs, alcohol, tobacco or weapons are permitted.

3.  Participants must respect the rights and property of others.

4.  Participants and parents / guardians are responsible for any and all damages caused by the participant.

5.  Failure to abide by code may result in participant removal, by parent, from the event.