Ice Skating

Participating Parish / Group Name: Church of the Blessed Sacrament

General Release and Liability Waivers

I, [your name], grant permission for my child(ren), [your child(ren)'s name(s)],to participate in this diocesan event that is located at location away from the parish site.  This activity will take place under the guidance and direction of diocesan employees and/or volunteers from the Diocese of Lafayette-in-Indiana.  As parent and/or legal 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 the Diocese of Lafayette-in-Indiana 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 Diocese of Lafayette-in-Indiana, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur any action brought against them as a result of such injury or damage unless such claim arises from the negligence of the parish/diocese. 

Medical Matters and Release

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 my 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: 

Other Medical Treatment

 In the event it comes to the attention of the parish, its officers, directors, or agents, and the Diocese of Lafayette-in-Indiana, 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)

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 are listed above:

Completion of Registration Form

I verify that I have read the above listed information regarding medical treatment, including but not limited to emergency medical treatment, other medical treatment, and necessary dispensing of medication.  I have included my signature with the appropriate statements which are applicable to my child.  I have attached any additional medical information as necessary for the participation of my child in the event.