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MINOR PARTICIPANT WAIVER AND RELEASE OF CLAIM

- MINOR PARTICIPANT WAIVER AND RELEASE OF CLAIM
- Dear Parent or Legal Guardian:
  Your son/daughter/ward has elected to participate in the activity that is described below. Participation in the activity may require personal transportation to locations away from your home site. This activity will take place under the guidance and supervision of adult chaperones, coaches, diocesan employees, and/or other volunteers.
  If you would like the child named herein to participate in this event, please complete, sign and return the following statement of consent, indemnifcation and release of liability.
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  Name of minor child, Birth date, & Sex Please enter valid data.
  
  Parent/Guardian Name, and Address Please enter valid data.
  
  Emergency Contact Information: Home phone & Work/Cell phone Please enter valid data.
  
  Accident/Hospitalization Insurance Carrier Name Please enter valid data.
  
  Policy Number: Please enter valid data.
  
  Carrier Phone Number: Please enter valid data.
  
  I hereby grant permission for the above named child to participate in the following activity: Please enter valid data.
  
  THE UNDERSIGNED, ON BEHALF OF THEMSELVES, THEIR HEIRS, SUCCESSORS, AND ASSIGNS, AND ON BEHALF OF THE ABOVE NAMED CHILD, THEIR HEIRS, SUCCESSORS, AND ASSIGNS, HEREBY AFFIRMATIVELY STATES AND AGREES AS FOLLOWS:
  
  I hereby waive, release and agree to indemnify, hold harmless and defend the Roman Catholic Diocese of Charlotte, included but not limited to any and all associated institutions and/or entities, its/their officers, directors, employees, volunteers, coaches, representatives, participating individuals and agents (collectively referred to as the “Diocese”) from any and all claims arising from or in any way connected with the activity referred to herein, or in connection with any illness or injury (including death) and/or cost of medical treatment in connection therewith, without limitation. The above shall include reasonable attorney’s fees and expenses incurred by the Diocese in any action brought against them as a result of any such claim(s), without limitation.
  
  I consent to the method of transportation and the conditions and supervision of said event and/or activity. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor child.
  
  In case of an emergency, I give my permission for the above named child to be taken to a physician and/or hospital, by either the supervisor in charge, or by an adult authorized by the supervisor in charge, and to be administered any and all medication reasonably necessary for treatment. I understand that every reasonable effort will be made to contact me. If I cannot be reached, however, I hereby give permission to hospitalize and secure proper treatment (including surgery and medication) for the above named child. The cost of any medical care or treatment obtained for the benefit of the above named child shall be my expense and not paid by the Diocese.
  I, and on behalf of my family, heirs, and assigns, hereby grant to the Parish/School/Agency and/or The Roman Catholic Diocese of Charlotte herein referred to collectively as the “Diocese”, permission to record on photography film and/or video, whether digital or otherwise, pictures, images and/or reproductions of my child(ren)’s participation and/or my families participation in this activity. I agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, social media, internet or other printed materials that the Diocese deems to be an appropriate use, and further that such use shall be without payment of fees, royalties, special credit or other compensation. I agree to indemnify and hold harmless the Diocese, its agents, representatives and assigns from any and all claims regarding the use of said material. Furthermore, I hereby waive any and all claims that I may have, or hereafter acquire, regarding the use of said material by the Diocese, its agents, representatives and assigns.
  
  Does your child have any restrictions, limitations, special needs and/or medical needs? YES NO , IF YOU ANSWERED YES, ATTACH A DETAILED DESCRIPTION OF ANY RESTRICTIONS, LIMITATIONS, SPECIAL NEEDS, MEDICAL NEEDS, ALLERGIES, PRESCRIPTIONS, MEDICATIONS, AND
  OTHER INFORMATION THAT I DEEM NECESSARY TO PROTECT MY CHILD. It is my responsibility to make arrangements to have any medications administered to my child. I have been informed and it is my understanding that I cannot rely on any Parish/School/Staff and volunteers to administer ANY medications without my prior arrangements. I understand and agree that the failure to attach said report and/or include relevant information shall be conclusive proof, for all matters, that my child is otherwise in good health. Irrespective of said disclosures, I assume all responsibilities for the health of my child.
  This Minor Participant Waiver and Release of Claim shall be in effect for the entirety of my child’s participation in this activity, continuing from year to year, and shall not expire unless revoked by me in writing.
  
  Type your name below to sign: REQUIRED Please fill out this field. Please enter valid data.
  
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