Diocese of Orange

DIOCESE OF ORANGE

ADULT PERMISSION & RELEASE FORM

HOLYSPIRITCATHOLICCHURCH

YOUTH MINISTRY

Event/Program:OC Steubenville Youth Conference

Location:Bren Event Center, University of California Irvine

100MESA RD IRVINE, CA 92697

Date: Friday July 7 @ 12pm to July 9th @ 1pm

PICK UP AND DROP OFF AT UCI

Cost: $200

(Please Print)

Participants Name:______Date of Birth: ___/___/___

Home No.:______Cell No.:______

Family Physician:______Phone No.:______

Insurance Company:______Policy No.:______

Allergies/Medical Problems/Disabilities______

Special Dietatry Needs______

Person to notify in case of emergency: ______Phone No.:______

I, ______, age ______, an adult, wish to participate in all Holy Spirit Church’s Youth Ministry Activities. I agree to cooperate and conform with directions and instructions of parish, school or diocesan personnel responsible for these Activities.

As a condition thereof, I hereby release and discharge the Diocese of Orange, its constituent organizations including but not limited to The Roman Catholic Bishop of Orange, a Corporation Sole, and their officers, employees and volunteers from any and all claims for personal injuries or property damage that I may suffer as a result of my participation in the activities described above, whether or not such injuries or damage are caused by the negligence, active or passive, of any of the entities, individuals named or described above.

I, hereby warrant and represent that I am physically fit and capable of participating in such activities. I make this warranty and representation on the basis of advise given me by a duly licensed medical doctor within the last six months, and I know of no change in my medical condition since receiving such advice that would affect the opinion of the said medical doctor. I agree that in the event I am injured as a result of my participation in the above named activities, including transportation to and from these activities, whether or not caused by the negligence, active or passive, of the parish, school, or diocesan youth activities program or any of its agents or employees, recourse for the payment of any resulting hospital, medical, dental treatment or related costs and expenses will be first had against any accident, hospital, medical, dental insurance, or any available benefit plan of mine.

I agree to abide by the rules and regulations, policies and procedures, governing the above named activity and to obey any instructions given by person or persons having supervision and control over the activity, and the Diocesan Director of Youth and/or Young Adult Ministries.

I, hereby authorize the making of photographs, motion pictures, video tapes, recordings, or other memorializing of said event and my participation therein, and the publication and duplication or other use thereof. I hereby waive any rights to compensation or any right that I otherwise might have to limit if to control such making or use.

I, hereby give permission to the physician, nurse, dentist, or licensed care staff selected by the supervisory personnel then present to render medical, dental or other appropriate treatment deemed necessary and appropriate by the physician, nurse, dentist, or licensed care staff.

Signature______Date:______