Form Ch-1 - Parental/guardian Consent Form And Liability Waiver - Diocese Of Birmingham

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Diocese of Birmingham in Alabama - Form CH-1
Parental/Guardian Consent Form and Liability Waiver
Type or Print Clearly All Information
Child _____________________________________ Sex ____ Date of Birth __________________
Parent(s)/Guardian(s)___________________________________________________________
Home Address_______________________________City________________State_____Zip___________
Home phone (
)_______________________ Other phone(
)_____________________________
I, (name of parent or guardian) ___________________________________, grant permission for my child (name
of child) __________________________________________ to participate in this parish youth event that
requires transportation to a location away from the parish site. This activity will take place under the guidance
and direction of personnel from _________________________________________________ parish/school
A brief description of the activity follows:
Date of event/activity: ______________________________________________________
Type of event/activity: ______________________________________________________
Destination of event/activity: _________________________________________________
Name and Location of overnight lodging (if applicable) ______________________________________
Individual in charge of and responsible: ________________________________________
Estimated time of departure and return: ________________________________________
Mode of transportation to and from event: ______________________________________
I do hereby further give consent for all emergency medical care (including surgery, if deemed necessary and recommended by
at least two attending physicians) prescribed by a duly licensed physician for my child in the event of injury or illness to my
child during the above named activity. This emergency medical care may be given under whatever conditions are deemed
necessary, or whatever conditions may then and there exist, so as to preserve and protect the life, limb, health and well-being
of my child.
In consideration of the parish or school allowing my child to participate in this event, I do hereby agree to forever indemnify,
exonerate, hold-harmless and defend the owner and driver of the private motor vehicle, the parish, the pastor, and staff
members and all youth ministry personnel, and the Bishop of Birmingham in Alabama, a corporation sole, and in said bishop’s
individual capacity, and their respective successors in office, from all claims, demands, actions, and causes of action, arising
out of or in any way pertaining to any bodily injury or illness, including death, incurred by my child during the course of any said
activities, and including emergency medical and/or surgical treatment for my child and whether or not said claim, demand,
action or suit is based on, or alleged to be based on, in whole or part, the negligence, wantonness, or other similar conduct of
any of The Indemnitees.
Parent sign Initials here ___________
This Indemnity applies, in all events, to the extent that such an injury, damage, illness, or death to my child is not covered by
applicable or enforceable liability insurance available to The Indemnitees, or when the amount of liability exceeds the said
insurance policy limits. I assume all risks and hazards incidental to or attendant with my child’s participation in the above
named activity, and in each phase of it.
I request that in the event of any medical or other emergency involving my child during the above named event, when neither
myself or the child’s other parent is readily available to be contacted by phone, that the adult supervisor contact the following
person, who will have authority to speak for me with respect to the emergency needs of my child.
Alternate Contact: _____________________________________ Relationship: ______________________
Phone(s) of Alternate: _____________________________________ ________________________________
Signature(s) of Parent/Guardian: ____________________________________________________
Form CH-1
02/2001

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