Adult consent & emergency medical release form
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- Navigate this page:
- (Middle Track at Eucharistic Congress)
- Insurance Carrier
- In Emergency, Notify: ______________________________________ Phone: ___________________ Relation: _____________ Child Youth Protection Policy
- If you are not yet cleared, or your paperwork has expired, you will be asked to fill out paperwork, including a background check.
- In signing this form, I certify that all information contained herein is true and accurate to the best of my knowledge.
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I, (please print)____________________________________ do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone these weekends, also the Archdiocese of Atlanta and its representatives, successors, supervisors, sponsors, organizers and participants for any injuries in connection with the (Middle Track at Eucharistic Congress) that is sponsored by (The Archdiocese of Atlanta). . I likewise release from my responsibility any person transporting myself to and from any of the activities. I also give my permission to seek emergency care if an injury or accident should occur. I hereby grant permission for publication of group (two or more persons) photos taken at this event. I also give permission to seek any emergency care should I be involved in any accident or be injured in any way during such events named above. I understand that in any such instance, all attempts will be made to contact the emergency name listed below. In the event that they cannot be contacted, I hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery should I become incapacitated. I also agree that I am legally responsible for all/any personal actions during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of my actions/behavior. Insurance Carrier: _________________________________ Policy #:______________________________________ Insurance Phone #: _________________________ Birth day: ____________________________________ I am allergic to: ________________________________ Current medication (and dosage): ________________________ Other medical, physical, or general information: __________________________________________________________________ In Emergency, Notify: ______________________________________ Phone: ___________________ Relation: _____________ Child & Youth Protection Policy It is the policy of the Archdiocese of Atlanta to have all adults volunteers complete and pass the Safe Environment profile and go through a background check before volunteering with any youth. Additional paperwork may be necessary. If you are not yet cleared, or your paperwork has expired, you will be asked to fill out paperwork, including a background check. Applicant’s Signature:_____________________________________________ Date:_______________ Printed Name:________________________________________ In signing this form, I certify that all information contained herein is true and accurate to the best of my knowledge. Adult, pg. Directory: wp-content -> uploads uploads -> 587 Return function, r i(X) r i(0) r i(1) r i(2) r i(3) 1 0 2 4 6 Thermal Station, I 2 0 1 5 6 3 0 3 5 6 10 uploads -> The Case Against the nypd’s Quota-Driven ‘Broken Windows’ Policing What Is It? uploads -> For want of a nail uploads -> Police Militarization uploads -> Stop Militarizing Law Enforcement Act of 2014 uploads -> 2017 afoCo Landmark Scholarship Program uploads -> Instructions for the Preparation of Camera-Ready Contributions to the Conference Proceedings uploads -> Medical Radiography Program uploads -> Ihbb asian Championships 2014 middle school bowl Round 4 First Quarter uploads -> Ihbb european Championships 2014 Bowl Round 4 First Quarter Download 8.49 Kb. Share with your friends:
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