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SEARCH Liability Form

- Youth Ministry

Parental/ Guardian Consent Form, Liability Waiver and Medical Information
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- Participant Last Name REQUIRED Please fill out this field. Please enter valid data.
- Participant First Name REQUIRED Please fill out this field. Please enter valid data.
- Participant Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
- State REQUIRED Please fill out this field. Please enter valid data.
- Zip REQUIRED Please fill out this field. Please enter valid data.
- Home Phone Please enter valid data.
- Parent/ Guardian's Name REQUIRED Please fill out this field. Please enter valid data.
- Parent Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Language Spoken by Parent REQUIRED Please fill out this field. Please enter valid data.
- Second Parent/ Guardian's Name Please enter valid data.
- Second Parent/ Guardian's Cell Phone Number Please enter valid data.
- Language Spoken by Second Parent Please enter valid data.
- Other Number Where Parent/ Guardian Can Be Reached During The Event Please enter valid data.
- Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Language Spoken by Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
- In consideration of the program in which my son/daughter will participate, I, as parent/ guardian of my son/ daughter, do hereby agree to allow my son/daughter to accompany the Diocese of Nashville's Office of Faith Formation to the SEARCH Retreat at Camp Marymount in Fairview, TN. I understand that transportation is not provided to or from this event.
  
  My child must comply with all Diocese of Nashille's rules and procedures. By granting this permission, I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Diocese of Nashville's Office of Faith Formation, its officers, directors, employees, and agents, and the Diocese of Nashville, 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, its officers, directors, and agents, and the Diocese of Nashville, its employees and agents and chaperones, or representatives associated with the event for reasonable attorney's fees and expenses which may incur for any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.
- I have read the above consent REQUIRED I agree Please fill out this field.
- Which SEARCH retreat will the participant be attending REQUIRED Please fill out this field.
- Insurance Information. Does the participant have current medical insurance? REQUIRED No, I do not carry medical insurance at this time I do carry medical insurance at this time Please fill out this field.
- Insurance Carrier Please enter valid data.
- Name of Insured Please enter valid data.
- Insurance Policy Number Please enter valid data.
- Family Doctor REQUIRED Please fill out this field. Please enter valid data.
- Family Doctor Phone Number REQUIRED Please fill out this field. Please enter valid data.
- My child has permission to take taking the following prescription medications while at the event. Please list medication name, dosage, and frequency
- Does your child have any medical issues or allergies we should be aware of? REQUIRED Please fill out this field.
- Does you child have any dietary restrictions?
- First-Aid Consent REQUIRED I hereby grant permission for non-prescription (including but not limited to acetaminophen, ibuprofen, throat lozenges, cough syrup, Benadryl, etc.) to be given to my child if appropriate. No medication of any type can be administered to my child unless the situation is life-threatening or emergency treatment is required. Please fill out this field.
- In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or sugical 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, please contact the emergency contact above.
- I have read the above statement REQUIRED I agree Please fill out this field.
- In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participants parent/guardian.
- I have read the above statement REQUIRED I agree Please fill out this field.
- Participant- I agree to abide by any/all policies established for this event/activity. Should I not be able to maintain the guidelines and expecations of the adults and my peers, I understand there will be consequences for my actions, including being removed from the activity and being sent home at my parent/guardians expense.
- I have read the above policy REQUIRED I agree Please fill out this field.
- Parent/ Guardian -- I fully understand the foregoing statements and sign this Medical Information and Consent Form knowingly, freely, and willingly. (Please type full name below stating the above information is true).
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SEARCH Liability Form

Parental/ Guardian Consent Form, Liability Waiver and Medical Information