Diocesan Consent and Medical Release Form

Participant Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Registered Parish REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Age (at start of event) REQUIRED Please fill out this field. Please enter an integer (number).

Gender REQUIRED Male Female Please fill out this field.

Email REQUIRED Please fill out this field. Please enter an email address.

Home Phone Number Please enter a phone number.

Cell Phone Number Please enter a phone number.

Full Home Address REQUIRED Please fill out this field.

Consent and Release

General:
By signing this waiver form, I acknowledge that my child is physically and mentally able to participate in youth ministry activities. I acknowledge that there are certain risks involved in said activities. I release The Diocese of Trenton, its affiliates, volunteers, and employees of all responsibilities for any injuries to body or property that may occur to my child during the course of these activities. In the event of an emergency in which I or the alternate contact cannot be reached, I authorize the adult leaders to make medical decisions for my child and administer first aid if deemed necessary. I further agree to indemnify and hold harmless The Diocese of Trenton and its affiliates, volunteers, and employees of any and all claims arriving from the participation in activities or as a result of injury or illness during such activities. I have read this Waiver Form and am fully aware of its contents.

Publicity:
On occasion, the Diocese of Trenton takes photographs or makes an audio or video recording of children and/or adults involved in parish/school/youth activities. I consent to the use of any such photographs or audio or video recordings of the individual named here to be used, distributed, or displayed as agents of the Diocese of Trenton as seen fit (e.g., Diocesan website, social media, The Monitor, etc.).

Transportation:
I hereby grant the Diocese of Trenton and its agents to transport my child during the aforementioned event. Transportation to and from said event is to be decided between myself and the Youth Ministry program to which my child belongs. I understand that this event/activity/retreat may take place outside of my parish and that it is under the direction and guidance of the Diocese of Trenton, along with the supervision of other volunteers/employees. I agree that in consideration of my child being permitted to join said event/activity/retreat, I hold each harmless and indemnify the Parish, the Diocese of Trenton, and their agents against any and all forms of claims for injury to my child involving said event/activity/retreat.

Acknoweldgement REQUIRED I acknowledge I have read and consent to the statement above and sign digitally here: Please fill out this field.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Participant Medical Information

Health Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Primary Insured (policy holder): REQUIRED Please fill out this field. Please enter valid data.

Relationship of policy holder to participant REQUIRED Please fill out this field. Please enter valid data.

Account Number REQUIRED Please fill out this field. Please enter valid data.

Physician Name: REQUIRED Please fill out this field. Please enter valid data.

Physician Phone REQUIRED Please fill out this field. Please enter valid data.

Medical conditions (check all that apply); add details below: REQUIRED Epilepsy Asthsma Diabetes Psychological Condition (e.g., depression, bipolar disorder, anxiety, etc.) Heart Condition Currently taking medication Other None apply Allergies Please fill out this field.

Please list details about above issues and share any other pertinent medical information.

Other needs (dietary or other):

Emergency Contact Information

Please list a parent/guardian for the first and (if possible) second Emergency Contacts below. The third Emergency Contact should be a trusted non-parent/guardian over 18 years of age.

Emergency Contact REQUIRED Please fill out this field.
Emergency Contact 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Email Please enter an email address.
- Would like to be added to email list: Yes, please No, thank you
- Primary Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Secondary Number Maximum 20 characters Please enter a phone number.
Emergency Contact 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Email Please enter an email address.
- Would like to be added to email list: Yes, please No, thank you
- Primary Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Secondary Number Maximum 20 characters Please enter a phone number.
Emergency Contact 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Email Please enter an email address.
- Would like to be added to email list: Yes, please No, thank you
- Primary Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Secondary Number Maximum 20 characters Please enter a phone number.