NCYC 2015ADULTForm withNO Archdiocesan Transportation: Page 1 of 2

ARCHDIOCESE OF CINCINNATIPERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY

  1. I, the undersigned will participate in the activity described on the Activity Information form and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes and schools within the Archdiocese (the “Archdiocese”), agents, representatives, volunteers, and employees of the Archdiocese, from any and all liability, claims, judgments, cost and expenses, including attorneys’ fees, arising out of any injury or illness incurred by me while participating in or traveling to or from the activity and further agree not to bring or prosecute or allow to be brought or prosecuted (including but not limited to prosecution through subrogation) in my name, any claims, lawsuits or actions against the Archbishop, and the officers, agents, representatives, volunteers and employees of the Archdiocese.

2.I further understand that my participation is purely voluntary and is a privilege and not a right. I elect to participate in spite of the risks.

3.I agree to cooperate with the Archbishop or his agents in charge of this activity.

4.I appoint the Archbishop or his agents acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, with respect to the following matters if any injury, illness of medical emergency occurs during the activity or related travel:

(i)To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our representative shall deem necessary or appropriate for my best interest.

(ii)I understand that the agents of the Archbishop will make a reasonable attempt to contact the listed emergency contact as soon as possible in the event of a medical emergency.

5.This power of attorney shall lapse automatically upon completion of NCYC and related travel.

6.I agree that the Archbishop or his agents, including local parishes, may use my photograph/video for promotional purposes, website and office functions, and hereby release the Archbishop and his agents from any liability resulting from such use.

7.I agree that the Archbishop or his agents are not and shall not be responsible for assuring that I take any medications, prescription or otherwise, which are indicated on the medical information side of this form.

8.This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.

I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission, Release and Medical Power of Attorney shall be effective and binding upon me and my own personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will.

*Participant Name: NickName on Badge:

*Parish/School Group: *Gender: M___ F___

Check all that apply:PRIESTDEACONREL. SISTER/BROTHERNURSE/DOCTOR

*Participant Signature: *Date:

Participant Cell (if applicable):() Home phone: ()

*Emergency Contact*Phone ()

*Indicates required field

NCYC 2015ADULTForm withNO Archdiocesan Transportation: Page 2 of 2

Additional Participant Information — Please Print Clearly

Address City/St/Zip

Ethnicity:Asian/Pacific IslandBlackHispanicNative AmericanWhiteMulti-EthnicOther

Special Needs: Wheelchair Access Hearing Impaired Visually Impaired Mobility Impaired

Medical Information — Please Print Clearly

Participant Name *DOB(mm/dd/yy) / /

Social Security #:*

Medical Insurance Co. Policy No.

Member Name Phone:day: () eve: ()

Member birth date:(mm/dd/yy) / / Member’s Soc. Sec. # *

Family Physician: Phone #: ()

Allergies (especially foods):

Special Dietary Concerns:

Current Medications:

Chronic conditions (i.e., epilepsy, diabetes):

* Social Security numbers are optional. Please note that some hospitals WILL NOT treat without it.

ACTIVITY INFORMATION

Completed by Church Agency - Please Print

One-Time Activity

Church Agency Arch of Cincinnati Office of Youth Young Adult Ministry Activity 2015 National Catholic Youth Conference

Location The Marten House Hotel and Lilly Conference Ctr, Indiana Convention Center and Lucas Oil Stadium, Indianapolis, IN
Emergency No. (513) 470-5241 (Bob Wurzelbacher mobile phone) Cost: $395 per person

Starting Date/Time Thurs., November 19, 2015, time TBAEnding Date/Time Sun., November 22, 2015, time TBA

Type of Transportation from Cincinnati/Dayton: Meeting and Drop-Off Place

Activities Involved Convention events and activities (see schedule)

Parish/School Group Leader: Telephone No.

NCYC Group Leader Bob Wurzelbacher, Associate Director, OYYAM Telephone No.(513) 421-3131 x2742 (office)

Other Information Put shuttling information here

COPY THIS DOCUMENTDOUBLE-SIDED!

Instructions for filling out the No Archdiocesan Transportation Form

this page is for information only and does not need to be copied and/or returned to the archdiocese

If you are not electing to utilize Archdiocesan-provided transportation for your trip to the National Catholic Youth Conference, you need to make some unique changes to the standard form, before printing it out and having your youth and parents sign it. This is why this form is provided as an editable, Word document.

Here are the changes you MUST make:

  1. Type of transportation: An example of how it might be filled in is below:

Type of Transportation from Cincinnati: car caravan Meeting and Drop-Off Place St. Thomas Parish

  1. Parish/School group leader: Because there is significant time when you are transporting your youth places during this convention, you should be additionally listed as a contact number.
  1. Other Information: a comment on how shuttling will take place between the hotel and the convention center. Most likely, you will simply put something like: ‘

Other Information: Daily shuttling by car between the hotel and the convention center

Other changes you MAY make:

  1. Emergency number: You may additionally list your own cell phone as an emergency number (but make it an additional one, not a replacement of the Archdiocesan leader phone)
  1. Cost: Since you are providing your own transportation, you may charge your youth something for that, making their cost different from what you send the archdiocese. You should put what you are charging on this form.

As always, remember these rules about transporting youth:

  1. By mandate of the Ohio Department of Education, a school group MUST transport by bus. Only parish groups have the option of organizing car caravans.
  2. 15-passenger vans are prohibited by the General Secretary of the USCCB.
  3. All drivers must be 21 or older.
  4. In an automobile: one seat belt, one passenger.
  5. Church leaders should confirm a valid driver’s license and liability insurance coverage. (Seems like a pain, but well worth it if there is an accident).
  6. The driver’s insurance is the primary insurance coverage, so the Archdiocese recommends that drivers call their insurance company to put a temporary rider on their policy to carry liability of $1,000,000 for the duration of the trip. That can be done at minimal cost, and out of courtesy that cost should be picked up by the parish. (In the event of a catastrophic accident, archdiocesan insurance will cover a significant amount of medical expenses for the driver once that driver’s own health insurance plan has been maxed out, but this does not apply to any passengers, nor to any other vehicle the driver may have hit).