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St. Catharine Parish Youth Group
Parental Permission, Medical Release, and Code of Behavior Agreement
Please read, complete, and sign both sides of his form and return it to the Rectory. Incomplete forms will not be accepted.
Name of Participant:_________________________________
Phone:____________________________________________
Address:___________________________________________
City: _______________State:______________ Zip:_________
Date of Birth: _______________________________________
Male: _________Female:__________ Grade:______________
Adult Coordinator:___________________________________
Parish: St. Catharine Parish
Event: _____________________________________________
Date of Event: ______________________________________
Time of Departure: ________________________________________
Return: ____________________________________________
Release and Indemnification Agreement and Medical Power of Attorney. Participants under the age of 18 (eighteen) must have their parent or legal guardian sign this release and emergency medical power of attorney:
A. As a parent or guardian of the participant, I give my permission for my child or ward to register for and attend this event and further, in consideration of the acceptance by the Office of Youth Ministry of such registration, I agree individually, and on behalf of my child or ward, to the terms of the above release of liability.
B. I appoint the Bishop or his agents who are acting as leaders of the activity as my attorney-in-fact to act for me in my name and on behalf, in any way that I could act if I were personally present, with respect to the following matters if any injury, illness, or medical emergency occurs during the activity: to give any and all consents and authorizations to any physicians, dentists, 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 my attorney shall deem necessary or appropriate for the best interest of my child.
C. I, the lawful parent/guardian of (child), release from all liability, and indemnity and hold harmless the Bishop of Columbus, both individually and as trustee for the Diocese or any parish thereof (agents) from any and all liability, actions, causes of action, claims, judgments, cost or expenses, including attorney fees known or unknown at this time, arising out of or in any way related to any injury or illness incurred by my child while participating in or traveling to or from the activity.
D. I may revoke the powers and authority granted by me herein by written notice delivered to the Bishop or his agents who are acting or have previously acted hereunder. Without any such written notice, this power of attorney shall not be affected by my disability, incapacity, or adjudicated incompetence. This power of attorney shall lapse automatically upon completion of the activity and return of my child to the ending place.
MEDICAL INFORMATION
Name of Participant: ________________________________________
Phone: ____________________________________________________
Address: ___________________________________________________
Allergies: __________________________________________________
Medications: _______________________________________________
Chronic Conditions (Ex. Epilepsy; Diabetes):___________________
Medical Insurance: __________________________________________
Policy Number:______________________________________________
Address: ___________________________________________________
Phone: ____________________________________________________
Member’s Name: ___________________________________________
Phone: ____________________________________________________
Family Doctor: _____________________________________________
Phone: ____________________________________________________
Emergency Contact: ________________________________________
Phone: ____________________________________________________
CODE OF BEHAVIOR
All participants are expected to conduct themselves with Christian dignity, self-respect, and respect for others. To ensure safety and a positive experience for all, it is necessary to state and enforce the following:
1. Youth in attendance must stay and participate in the entire event. No one may leave the premises unless accompanied by their adult leader or adult chaperone with the knowledge and permission of the adult leader.
2. The possession or use of alcohol, tobacco, drugs or weapons of any kind is not permitted.
3. Foul language is not tolerated.
4. Participants must heed any and all directions of the staff.
5. Participants must respect the rights and property of others. Damage to or defacing of property will be the financial responsibility of the youth involved and their parents or legal guardians.
6. Failure to abide by this code of behavior may result in a phone call to parents/legal guardians, who will be required to immediately transport offending youth from the premises.
Thank you for your support in providing a safe, fun and faith-filled experience for the young people of the Diocese of Columbus.
I HAVE READ AND UNDERSTAND ALL CONTAINED IN THIS AGREEMENT:
Participant’s Signature: _______________________________________
Date:________________________________________________________
Parent/Legal Guardian Signature:______________________________
Date:________________________________________________________ | 
