Parent /guardian Consent And Emergency Medical Release Form Page 2
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2If you would like your youth to participate in this event, please sign and return the following statement of consent and
release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may
result from any personal actions taken by your youth.
I hereby consent to participation by my youth ___________________________________ in the event described
above. I understand that this event will take place away from the parish grounds and that my youth will be under the
supervision of the designated supervisor on the stated dates. I further consent to the conditions stated above on
participation in this event, including the method of transportation.
In consideration for the opportunity for my child to participate, and fully recognizing that such an undertaking
involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release,
absolve,
indemnify
and
agree
to
hold
harmless
the
Diocese
of
Pensacola-Tallahassee
and
______________________________Parish, and their employees, agents, volunteers, and other persons acting on their
behalf. Neither the Diocese of Pensacola-Tallahassee, _____________________________ Parish, nor said agents,
employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or
indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it
voluntarily and with full knowledge of its significance.
EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of
Pensacola-Tallahassee, and ______________________________ Parish, through its authorized representatives, to
transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We
additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever
medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do
hereby release the Diocese and ________________________________Parish, and their authorized representatives
from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment.
I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician
or hospital. If I/we are unable to be reached, please contact the following:
Emergency contact and relation to participant________________________________________________
Address and Phone Number _______________________________________________________________
Finally, I/we hereby give permission for the Diocese of Pensacola-Tallahassee and any of its affiliated organizations,
including, but not limited to The Catholic Compass, to use the name of my child and/or his/her photograph for
promotional, news, or public relations purposes in print and/or electronic media.
________________________________________________________
Print Parent/Guardian Name
________________________________________________________
___________________
Signature of Parent/Guardian
Date
This form must be with the head chaperone at all diocesan and parish events
Revised 10/2010
Parent / Guardian Consent and Emergency Medical Release Form
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