Saint Rita PARISH

PERMISSION, RELEASE, AND AUTHORIZATION TO SEEK MEDICAL TREATMENT (MINORS)

I, the parent or lawful guardian of       Child/Children listed       (the “child”), give permission for my child to participate in the __VBS_______ activity described further on the Activity Information form (the “Activity”) sponsored by ___Saint Rita___ Parish (the “Parish”).  In exchange for and in consideration of the opportunity for my child to participate in the Activity, I agree to the following:

1. I understand what is involved in the Activity and acknowledge that I have had the opportunity to ask questions regarding the scope and nature of the Activity.  I recognize, as with any activity, the possibility and risk of injury associated with my child’s participation in the Activity and that such injury can include, but is not limited to, serious bodily injury, permanent disability, paralysis, and death.  I understand that such injuries can occur for any number of reasons which are both foreseeable and unforeseeable and which include, but are not limited to, my child’s own actions or inaction, the actions or inaction of others (whether negligent, intentional, or otherwise), and equipment failure.

2. I further understand that my Child’s participation in the Activity is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, agree to my Child’s participation in the Activity in spite of the risks. I and my spouse assume, for ourselves and on behalf of our minor child, all risks in connection with my child’s participation in the Activity.

3. I agree to instruct my child to cooperate with those persons in charge of the activity.

4. To the fullest extent allowed by law, I, on behalf of myself, my spouse, my minor child, as well as our respective heirs and assigns, executors, all other legal representatives and any others claiming through us or on behalf of us, hereby agree to release, discharge, hold harmless and indemnify the Parish, the Roman Catholic Diocese of Cleveland, the Bishop of the Roman Catholic Diocese of Cleveland, as well as their respective clergy, officers, employees, agents, representatives, attorneys, sponsors, and volunteers from and against all claims, judgments, liability (of any nature or extent) which in any way arise out of or relate to my child’s participation in the Activity, whether foreseen or unforeseen, regardless of the cause (including, but not limited to, the negligence of any person).

5. I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.

6. In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the Parish to provide for, seek, and authorize medical treatment for him/her in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery.

8. I [ X ] consent and grant permission [ ] do not consent and grant permission for the Parish and/or its agents to record (in writing or otherwise), photograph, audio record, and video record my minor child’s name, image, likeness, spoken words, in any form (the “Recordings”), and to display, release, exhibit, publish, or distribute the Recordings, or any part thereof, for the purpose of and in connection with any material that may be created by or on behalf of the Parish including, without limitation, through the Parish’s bulletin boards, social media, website, print and electronic media, marketing publications, public relations and communications materials and/or presentations, and any other uses as may not be contemplated herein, without further notice or compensation, and I agree that the Recordings shall constitute the sole property of the Parish.  I further agree to release the Parish, the Catholic Diocese of Cleveland, and the Bishop of the Diocese of Cleveland, and their respective officers, directors, agents, employees and/or attorneys from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented

7. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.

I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission, Release and Authorization to Seek Medical Treatment shall be effective and binding upon me, my Child, and my own and my Child’s personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will.

Acceptance of Terms