Archdiocese of Dubuque - WCYM

Parental/Guardian Consent Form and Liability Waiver

Participant’s name: _________________________________________________________ Birth date: ________________________

Parent/Guardian’s name: ____________________________________ Address: __________________________________________ 

City __________________________ Zip ______________Home phone: _____________________  Cell Phone: ________________

Email: _________________________________

I,__________________________, grant permission for my child, ______________________ to participate in this school/ parish event that requires transportation to a location away from the school/parish site. This activity will take place under the guidance and direction of school/parish employees and/or volunteers Waterloo Catholic Youth Ministry. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Waterloo Catholic Youth Ministry, its officers, directors and agents, and the Archdiocese of Dubuque, chaperones, or representatives associated with the event, arising from or in connection with my child attending the event(s) or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its  officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representative associated with the event for reasonable attorney's fees and expenses arising in connection therewith.

Signature: ____________________________________________________________________Date: _____________________

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.

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 #:_______________________________

Parent Signature:_________________________________________________________________ Date:___________________

Other Medical Treatment: In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, 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.

Signature:_________________________________________________________________ Date:_________________________

Please sign only ONE of the following two statements:

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:_________________________

-OR-

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/school will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc…  ________________________________________________________________________________________________________

Does child have a medically prescribed diet?  If so, please describe: ________________________________________________________________________________________________________

Any physical limitations? ___________________________________________________________________________________

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

_______________________________________________________________________________________________________

* Please feel free to contact us if you have any further health concerns about your child.  I can be reached by email at wcym@mchsi.com and phone at 319-610-1087.

Kim Swanson-Huff

WCYM Director