Medical Information, Consent Form and Liability Waiver

Participant Information
Participant's name
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Date of birth //
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Parent/Guardian's name
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Home address
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Home phone number --
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Cell phone number --
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Youth minister's name
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Youth minister's cell phone number --
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Parent/Guardian Information
By entering both the name of the child and parent/guardian into the following box, I grant permission for my child to participate in this diocesan/parish/school event that requires transportation to a location away from the parish/school site. This activity will take place under the guidance and direction of parish/school employees and/or volunteers from St. Paul's Parish and/or School.
Parent/Guardian name and name of child
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A brief description of the activity follows:
Type of event:
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Date of event:
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Destination of event:
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Individual in charge of group:
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Estimated date and time of departure:
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Estimated date and time of return:
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Mode of transportation to and from event:
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As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant").
By entering my name in the following box, I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns to hold harmless and defend St. Paul's Parish/School, its officers, directors, employees and agents, and the Diocese of Boise, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and the Diocese of Boise, its agents and chaperones, or representatives associated withe the event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of Boise.
Name of parent/guardian
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Date //
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Medical Matters
I hereby warrant that to the best of my knowledge, my child is in good health and I assume all responsibility for the health of my child.
Of the following statements pertaining to medical matters, sign ONLY those that are applicable.
Emergency Medical Treatment
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name
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Relationship
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Phone --
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Family doctor
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Family doctor phone --
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Family health plan carrier
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Policy #
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Signature
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Date //
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Other Medical Treatment
In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Diocese of Boise, chaperones, or representatives associated with the activity, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).
Signature
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Date //
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Medications
My child is taking medication at present. My child will bring all such medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
Text (Multiple Lines)
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Signature
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Date //
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No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
Signature
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Date //
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I grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.
Signature
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Date //
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Specific Medical Information
The parish/school will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.)
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Immunizations: Date of last tetanus/diphtheria immunization
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Does child have a medically prescribed diet?
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Does child have any physical limitations?
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Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
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Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition.
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Does the child have any special medical conditions that we should be aware of?
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Photographs and Videos
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced periodically by the Diocese of Boise or local parishes. (Participants would not be identified without specific written consent. Parents/guardians who do not wish their child(ren) to be photographed or filmed should so notify the parish/Diocese of Boise in writing. Please note that the Diocese of Boise has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate.