POwer uP Middle School Ministry

Child/Teen Full Name

What Grade is the Child/Teen in?

School of Attendance

Date of Birth

Father/Guardian's Full Name

Mother/Guardian's Full Name

Home Mailing Address

Email address

Email Address #2

The best phone number to reach you

Is the above phone number the best for "Remind"? If not, please provide one here

Emergency contact Full Name and their phone #

Medical Matters: I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical information and Consent Form if there are any changes to my child's health (Please, initial)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment (Please, initial)

Family Doctor

Family Doctor's phone number

Medications: I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. (Note: any/all prescriptions medications must be in original pharmacy container with young person's name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person's name on the container). I release and hold harmless Prince of Peace Catholic Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering medication (Please, initial)

Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:

My son/daughter is allergic to the following medications: (Please list below)

My son/daughter is allergic to the following medications (click on the box below to list them)

My son/daughter has had an episode of the following or has been diagnosed with seizures, asthma, diabetic

My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.); click on the box below to list them)

My son/daughter has had a medical surgery within the last six months and still under doctor's care? click on the box to type in the answer)

My son/daughter has a medically prescribed diet (please explain); click on the box below to type in your answer if needed)

My son/daughter has the following physical limitations: (click on the box below to list the limitations if any)

Immunizations current and up to date? (click on the box below to type YES or NO

Date of last tetanus/diphtheria immunization?

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

Insurance information: Do you carry medical insurance for your child at this time?

Insurance carrier

Name of insured

Insurance Policy number

I fully understand the forgoing statements and sign and date (by typing my name and date below) this medical information & consent form knowingly, freely, and willlingly

I, (you will type your name below) for valuable consideration received and for being allowed access to Diocesan property, activities, or events, expressly assign to Prince of Peace and the Diocese of Orlando, and to all of their current, former, and future agents and related entities (collectively, "the Diocese"), all rights, title and interest in, and to, the use of my and my child/ward's image of likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose ("the Property"). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Orlando. I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for nay purpose whatsoever, and I further waive all rights to any compensation for my and /or my child/ward's appearance of participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of Youth and Young Adult Ministry and/or the Diocese. Particpants' names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that my be covering the event in which my child(ren)ward(s) participate(s). I hereby waive any claims against and release the Diocese, its current, former, and future religious, emplyoees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property. This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward's name may be printed with photos/images in various publications, including non-Diocesan publications I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release (by typing my full name and date below)

Name of Parent/Guardian:

Name of Minor Child/Teen:

Name of Ministry Leader:

Name of Parish/School:

Approved Parent Communication Methods (Check all that apply):

Other. (please explain)

Approved Child/Teen Communication Methods (Check all that apply):

Other. (please explain)

Prince of Peace Parish

POwer uP Middle School Ministry

Medical Conditions Information: (Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)

In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant's parent/guardian.

Photography and Image Assignment, Waiver, and Release

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