Catholic Diocese of Austin
St. Mary's Catholic Center
ADULT CONSENT and RELEASE FOR MEDICAL TREATMENT
(For adult participants, 18 years of age or older.)
In Case Of Emergency, and in the event that I am not coherent or conscious, I hereby grant the staff of St. Mary's, permission to act on my behalf in seeking emergency medical treatment for myself in the event that such treatment is deemed necessary.
I hereby give my permission to those administering medical treatment to do so.
I further absolve and release St. Mary's Catholic Center, its Pastor, employees, and volunteers, as well as the Diocese of Austin and its employees, from any liability whatsoever when acting on my behalf in regard to medical treatment, and in any other respect deemed necessary should I become incapacitated.
I do hereby, absolve and release the above named for any injuries in connection with Kappa Theta Beta events, retreats, or activities from September 1, 2015 through August 31, 2016 provided that said injuries are not the result of gross, willful negligence.
I agree that I am legally responsible for all/any personal actions I take during this trip and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of my actions/behavior.
I/We likewise release from liability any person(s) transporting me, in a privately owned and/or leased vehicle, to and from any activities connected with the above named event(s), with the exception of gross negligence due either fully, or in part, to mechanical failure and/or operator error.
Name of Participant:______
Address:______City:______State:_____ Zip:______
Phone: ______
Insurance Company:______
Policy Number:______
Insurance Address / Phone: ______
Place of employment providing Insurance: ______
Additional comments regarding medical history, allergies, medications, or other conditions:
______
______
______
In the event of an emergency, please contact the person(s) named below:
Name: ______
Relationship: ______
Phone Number(s): ______
I acknowledge that my signature on the bottom of this page signifies that I am in agreement with all the statements on this form. Furthermore, I agree to abide by all policies and expectations regarding participation in St. Mary’s events as put forth by my parish and the Catholic Diocese of Austin's Ethics and Integrity in Ministry policy. I will refrain from any actions / behaviors that are not consistent with the teachings of the Catholic Church and any that could be potentially harmful to myself and any other participants.