Permission, Medical Authorization, and Indemnification Form

St. Sebastian’s Project H.O.P.E

Permission, Medical Authorization, and Indemnification Form

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Name of ParticipantAddress

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Phone Number

In consideration of ______, being allowed to participate in the St. Sebastian’s Project HOPE trip and intending to be legally bound. I do hereby release and forever discharge the Roman Catholic Diocese of Pittsburgh, the Bishop of the Diocese, Catholic Institute, St. Sebastian Parish, designated adult leaders of the trip, their agents and successors, from any / all actions or suits in law or equity which I / We might hereafter have by reason of injuries sustained by my child participating in, or in transit to or from participation in, the trip to Kentucky, to be held in the last week of June in the year in the date below.

In the event of that my son or daughter is detained by local authorities on a criminal matter, it is understood that the matter will be resolved between the parents and local authorities.

Medical Authorization

In the event of injury or illness to our child during his / her participation in the trip, we hereby give our permission for the necessary medical treatment to be given to our child. We, for ourselves, for our child, our respective heirs and our respective legal representatives, do hereby indemnify and hold harmless any representative of St. Sebastian’s Project HOPE Group or any designated adult leader of the trip from any / all claims, demands, and causes of action of whatever kind and nature for their actions taken pursuant to this authority.

We agree that in case of injury to my child, we will apply our hospitalization and / or accident insurance toward the payment of the expenses incurred and will not look to the Project Hope Group, and designated adult leader of the trip, or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury related costs.

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Mother’s SignatureFather’s Signature

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Guardian’s SignatureDate

Name of Insurer: ______

Policy Number: ______

Name of Employer: ______

Medical Information:

Individuals Name: ______

Date of Birth: ______

Have you had more than a brief minor illness or injury in the past year? ______

If so, explain: ______

Do you now take medications of any kind? ______

If so, explain: ______

Are you presently being treated? ______

If so, explain: ______

Have you ever been restricted from work, sports or swimming for any reasons? ______

If so, explain: ______

Do you have severe reactions to bee, hornet or wasp stings? ______

Do you get out of breath easily? ______

Do you tire easily? ______

Do you have / had sinus trouble? ______

Please check if you suffer from any of the following:

Asthma______

Fainting Spells______

Diabetes______

Rheumatic Fever______

Ear ache / infection______

TB______

Kidney Disease______

Hay Fever______

Allergies______

Severe Stomach Aches______

Menstrual Problems______

Ever had Chicken Pox______

Sleep Disorders______

If you have checked any of the above please use this space to explain in detail:

Immunization (Date of last inoculation):

Smallpox: ______

Diphtheria: ______

Tetanus: ______

Polio: ______

Are you allergic to any medication? ______

Name of family physician: ______

Physician’s Phone #: ______

Please make a not on any further information you deem important medical knowledge concerning your child that should be know. Thank you.