Faih Factor

Parental/Guardian Consent Form & Liability Waiver

Participant’s name: ______

Birth date: ______Sex: ______Grade in Fall 2018: ______

Parish: ______Adult Shirt Size: Mens Sm M Lg XL XXL

{circle one} Womens Sm M Lg XL XXL

Parent/Guardian’s name: ______

Home address: ______

Home phone: ______Business or cell phone: ______Email: ______

I______, request that the Faith Factor allow my/our son/daughter

Parent or Guardian Name

______to participate in the “Faith FACTOR” service week with the

Child’s Name

Fox Valley Catholic Youth Ministry Association (FVCYMA) from July 23-26, 2018. The event is for service, community bonding & spiritual growth. This camp may require transportation to a location away from the parish site. This activity will take place under the guidance and direction of Faith Factor staff and/or adult chaperones.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant"). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Faith Factor, FVCYMA, the participating parishes, its advisors/chaperones, officers, directors and agents, and the Catholic Diocese of Green Bay, or representatives associated with the activity for reasonable attorney’s fees and expenses arising in connection therewith. I further release any liability in the event my son/daughter is injured while participating in and/or traveling to and from the event in the rented or personally owned vehicles. Any behavior deemed unacceptable will result in the parent being called and the child picked up immediately. The undersigned parent consents to the use of likeness in any manner relating to communication production in any media

Parent/Guardian Signature:Date:

Participant:

_____ I want to be on a team with my friend: We are going to be splitting up into “service teams” during the week. You may know a friend who is signing up for the week. If you would like to be placed on the same team as him/her, please print his/her name below and we’ll do our best to try and place you on the same team. More than one friend request is not allowed.

Friend’s name: ______Parish: ______(Please limit yourself to one friend)

Parent: ___ I would be willing to drive and chaperone. Please send me the necessary forms.

NOTE:Please let us know if you are attending the Mass & meal so we have enough food, thanks! Dinner is FREE for family members.

Number attending 4:00 pm Mass on Thursday:______

Number attending Dinner after Mass on Thursday:______

Please send payment and form to your Parish Youth Minister or Religious Education coordinator

MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Emergency Medical Treatment:In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name & relationship: ______

Phone: ______Family doctor: ______Phone: ______

Family Health Plan Carrier: ______Policy #: ______

Signature: ______Date: ______

Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agents, and the Catholic Diocese of Green Bay, coaches, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).

Signature: ______Date: ______

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows: ______

Signature: ______Date: ______

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Signature: ______Date: ______

I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Signature: ______Date: ______

Specific Medical Information: The parish will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, animals etc.): ______

Immunizations: Date of last tetanus/diphtheria immunization: ______

Does child have a medically prescribed diet? ______

Any physical limitations? ______

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition:______

You should be aware of these special medical conditions of my child:______

**MEDIA RELEASE: This authorization form constitutes permission for my child(ren)’s participation in videotaping and/or photographs which may be taken during the program/trip. These could be used for further promotional videos, website promotions, fliers, or other diocesan or parish appropriate uses.

Signature of Parent/Guardian______

From the Catholic Mutual Group C.A.R.E.S. Program July 2001

Aon Risk Services – Green Bay Wisconsin 800-437-0555

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