St. Ambrose LIFETEEN Ministries

St. Ambrose LIFETEEN Ministries

April 27, 2016 Service Opportunity:St. Catherine’s Center for Children-Copson House

401 New Scotland AvenueAlbany NY

General Release and Liability Release Form

Name ______

Address ______

Birth Date ______Class of _____ Phone ______Email______

Parent’s Name(s)______Cell Phone ______

Parent

I grant permission for my child to participate in the event listed above coordinated through St. Ambrose Catholic Church, Latham. I understand that my child requires transportation to this eventby the staff and volunteers of St. Ambrose.

I grant permission, if needed, for my child to be evaluated, diagnosed, treated, and /or medicated in accordance with standard medical practice by licensed medical personnel. I relieve St. Ambrose Church and the Diocese of Albany of all responsibility and consequences that may arise as the result of this treatment.

I will not hold the Church of St. Ambrose, Diocese of Albany, or any and all other participating chaperones responsible in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment.

My child agrees to abide by all rules and regulations decided upon by the Church of St. Ambrose and the Diocese of Albany. I understand that neither the Church of St. Ambrose nor the Diocese of Albany will be held liable if my child fails to cooperate with said regulations and that any infractions of the rules may result in immediate dismissal from the event. I further understand that I will be responsible for any costs or other requirements for immediate transportation home. The participant will not be left unattended while waiting for transportation home.

Media/Photo Waiver: I hereby authorize and give my full consent to St. Ambrose LIFETEEN Chaperones to copyright and/or publish any and all photographs, videotapes and /or film in which my child or myself appear while participating in any programs sponsored or chaperoned by LIFETEEN Ministries. I further agree that they may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations.

(Signature of Parent or guardian) ______

Youth

As a participant of this event, I understand and agree to the rules and regulations as determined by the Church of St. Ambrose, St. Catherine’s Center for Children and the Diocese of Albany. I also understand and agree that I will notify my parents or guardian at the time of any infractions requiring my dismissal from the event and that I will be sent home at my own and/or my parent’s or guardian’s expense.

(Signature of Youth Participant) ______

Medical Information

Allergies ______Diet restrictions ______

Medications ______

Any physical limitations ______

Special medical conditions ______

Insurance Provider ______Policy # ______Primary policy holder______

In case of emergency and I cannot be reached please notify:

Name ______Phone ______Relationship to youth ______

Other information pertinent to their medical history ______

______

Office of Evangelization, Catechesis and Family Life

Roman Catholic Diocese of Albany

SELF–DIRECTED MEDICATION PERMISSION FORM

I, ______, the parent or legal guardian of

______(Name of child/youth) authorize the designation of specified parish personnel of St. Ambrose Parish of Latham, NY who are not licensed health care professionals, to supervise the administration of required medication, which is to be “self-directed” to my child.

Type of Medication ______

Dosage and Frequency of Administration ______

Beginning date _____/_____/_____ Ending date _____/_____/_____

I understand that every effort will be made to notify me immediately should it become necessary to obtain emergency medical treatment in connection with my child’s condition. The person(s) who should be notified and the telephone number(s) are:

Name ______Phone ______

Name ______Phone ______

In consideration of the acceptance of this authorization for the designation of the assistance for my child, I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all claims for damages I may have against said parish, their representatives, employees, successors and assigns, rising out of any and all injured sustained.

Date _____/_____/_____

Signature ______

(Parent/Legal Guardian)

10/1/08