Liability Waiver & Medical Authorization Form

___________________ Parish of _____________, Massachusetts (the “Parish”)

Acknowledgement and Assumption of Risk

The undersigned participant, parent and/or legal guardian, does hereby acknowledge that I am or he/she is

aware of the dangers and risks to person and property by participating in:

_____________________________________________________________________________________

Nevertheless, I, or the undersigned parent and/or legal guardian, voluntarily elect to participate in this

activity with knowledge of the danger involved, and hereby agree to accept and assume any and all risk of

property damage, personal injury, or death.

Medical Authorization, Indemnification and Waiver of Liability

In consideration for being allowed to voluntarily participate in the above-referenced event, I hereby:

a.) Consent to receive medical treatment, which may be deemed advisable in the event of injury,

accident or illness during this activity or event. This release, indemnification, and waiver shall be

construed broadly to provide a release, indemnification, and waiver to the maximum extent

permissible under applicable law;

b.) Agree to defend, indemnify, and hold harmless the Parish and the Roman Catholic Archbishop of

Boston, a Corporate Sole, and its agencies, officers, and employees from and against any and all

claims of any nature including all costs, expense and attorneys’ fees, which in any manner result

from actions during this activity or event; and

c.) Waive and release forever the Parish and the Roman Catholic Archbishop of Boston, a Corporate

Sole, and its agencies, officers, and employees from any and all liability for death, disability,

personal injury, property damages, property theft, or claims of any nature which may hereafter

accrue as a direct or indirect result of the participation in the activity or event.

Further, I affirm that I am at least 18 years of age and am freely signing this agreement. I have read this

form and fully understand that by signing this form I am giving up legal rights and/or remedies that may

otherwise be available regarding any losses sustained as a result of participating. I agree that if any

portion is held invalid, the remainder will continue in full legal force and effect.

READ BEFORE SIGNING

Signature: _______________________________________________

Date: ___________________

Printed Name: _______________________________________________________________________

Name of Minor, if applicable: _______________________________

Age of Minor: ____________

Emergency Contact Telephone No.: ______________________________________________________

Insurance Carrier Name and Policy No.: ___________________________________________________

Important Medical Information About Your Child (allergies, etc.): _ ________________________________________

____________________________________________________________________________________

Liability Waiver & Medical Authorization Form - Parish Of Massachusetts