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Youth Activity Permission Form

St. Dorothy Catholic Church

241. S. Valley Center Ave, Glendora, CA 91741

Youth First Name*

Answer required for "Youth First Name"

Youth Last Name*

Answer required for "Youth Last Name"

Gender*

Answer required for "Gender"

Male

Female

Date of Birth*

Answer required for "Date of Birth"

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

I, the undersigned below, request that my child be permitted to participate in the above activity. I am not aware of any physical or medical condition my child has that would prevent my child from participating fully in this activity. My son/daughter has the following medical needs, allergies or dietary restrictions*

Answer required for "I, the undersigned below, request that my child be permitted to participate in the above activity. I am not aware of any physical or medical condition my child has that would prevent my child from participating fully in this activity. My son/daughter has the following medical needs, allergies or dietary restrictions"

If my child needs to take medication while participating in this activity, I hereby give my child permission to and, if my child cannot self-administer, I give permission to the responsible staff members or chaperones to administer or to assist in the administration of my child’s medication. I also give permission to the responsible staff members, chaperones, medical practitioners and medical facilities to use their judgement in obtaining and providing medical treatment for my child should it become necessary to do so. I understand that health insurance benefits through St. Dorothy and the Archdiocese of Los Angeles, if any, may have limited application, and that I am entirely responsible for the cost of all medical treatment provided to my child. I agree to reimburse the location for the cost of any medical treatment and related expense incurred.

Release of Liability: As a condition of participating in this activity, I hereby hold harmless, release and discharge The Roman Catholic Archbishop of Los Angeles, a corporation sole, Archdiocese of Los Angeles Education & Welfare Corporation and the Location, their respective agents and employees and any parent/volunteer/chaperone, from any and all liability, loss or claims for personal injuries, wrongful death or property damage that I or my child may suffer as a result of participation in the activity described above.

Authorization And Release To Use Likeness:

I further grant the Released Parties the right to photograph and/or video or audiotape my child and further to display, use and/or otherwise exploit my child’s name, face, likeness, voice, and appearance forever and throughout the world, in all media, whether now known or hereafter devised (including, without limitation, in online web casts, television, motion pictures, films, newspapers, and magazines) and in all forms including, without limitation, digitized images, whether for advertising, publicity, or promotional purposes, including, without limitation, publication of Activity results and standings, without compensation, reservation or limitation.

Parent/Guardian First Name*

Answer required for "Parent/Guardian First Name"

Parent/Guardian Last Name*

Answer required for "Parent/Guardian Last Name"

Phone*

Number Required

Email*

Answer required for "Email"

Emergency Contact Information

Person to Notify in case of Emergency if Parent or Guardian is unavailable:

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Phone*

Number Required

Parent Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"