Off Property Form Participants Name
Grade Level
5th
6th
7th
8th
9th
10th
11th
12th
Chaperone
Date of Birth
Street Address (St., City, Zip Code)
Parent/Guardian Name
Cell Phone Number(s) of those that can be reached in case of emergency
Important! To be filled out by the Parent/Guardian for youth under 18 years of age and individuals age 18 or older and in high school.
In consideration of the program in which my son/daughter will participate, I, as parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to accompany Prince of Peace Catholic Church to:
Event/Location
Date/Time of event.
Transportation:
Method of Transportation
I acknowledge that Prince of Peace Catholic Church is providing transportation only from POP Parish to and from the event. I acknowledge and assume the risk of this transportation for my child. My child must comply with Prince of Peace Catholic Church rules and procedures. By granting this permission, I also waive any claims against, and RELEASE AND HOLD HARMLESS AND INDEMNIFY, Prince of Peace Catholic Church, The Diocese of Orlando, any of their religious, employees, volunteers, agents and representatives from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my child’s participation in the program.
Inputting your name below is the signature for this online form. Please type your name, signing and agreeing to the above statement.
Date Signed
Participant: In signing the line below, I agree to abide by any/all policies established for this event/activity. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand there will be consequences for my actions, including being removed from the activity and being sent home at my parents/guardian’s expense.
Participant's Name (typing is a form of signature for this online form).
Date Signed
Insurance Information: Fill out the info below.
Do you carry insurance at this time?
Insurance Carrier
Name of Insured
Insurance Policy Number
In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.
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
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.);
My son/daughter has had a medical surgery within the last six months and still under doctor's care?
My son/daughter has a medically prescribed diet (please explain);
My son/daughter has the following physical limitations:
Immunizations current and up to date? (click on the box below to type YES or NO
Yes
No
Date of last tetanus/diphtheria immunization?
You should also be aware of these special medical conditions of my child:
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
