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Female

Male

Youth

Youth Adult )18 and High School Graduate)

Adult Chaperone

Priest or Religious

Medical Professional

Church Employee

Parish- Sacred Heart of Jesus Pastor Rev. Msgr. William R. Richardson

Please list ALL allergic reactions: (Medications, Food, Insects, etc.)

Current Prescriptions: (Name, Dose, Frequency)

Special medical/mental conditions:  Yes / No  Please Describe:

Access Needs: (Please check appropriate boxes and/or explain special needs or concerns.)

Other

Mobility Impaired

Visually Impaired

Hearing Impaired - Interpretation Needed

Wheelchair Access

Are there any medications that should NOT be administered to this participant? (allergies, interactions etc.)

***If participant is under 18*** I hereby grant permission for nonprescription medication (such as acetaminophen, ibuprofen, throat lozenges, cough syrup etc.) to be given my child if deemed advisable.  Type the Signature of participant or parent/legal guardian if participant is under 18 In the space below. Signature: Todays Date: Primary Care Physician: Phone #: Primary Insurance: Policy Number: Group Number:

I understand and have been informed that taking part in this youth event involves the risk of injury, and that participation is voluntary. I understand that the program will have competent adult supervision and reasonable and appropriate measures will be made to minimize the risk of injury and/or accident for all participants. I hereby consent and authorize any staff members and/or adult volunteers under whose auspices the program for which my child or myself is being conducted, to secure emergency medical care or treatment that may be necessary for my self/child during the entire event. This consent and authority includes, but is not limited to, the ability to apply for admission to any health care facility, to arrange for and consent to health care procedures, and to arrange for any necessary transportation. This consent and authorization also includes the right to request, review and receive any oral or written information regarding my or my child’s physical or mental health including medical and hospital records and including the authority to execute any releases that may be necessary to obtain this information. Furthermore, I release and hold harmless any said staff member and/or adult volunteer from any liability as a result of that staff member or adult volunteer who acting in good faith is placed in a position of making decisions required for emergency care or medical treatment for my self/child. In case of an accident, injury or loss, neither my family nor I will hold the Diocese, the parish, nor any person or affiliate organization associated with the event, responsible or liable. I am hereby advised that photographs or video of participants may be taken during this youth event and used in publications, websites or other materials produced from time to time by the Office for Youth and Young Adult Ministry or the Diocese of Harrisburg. (Participants would not be identified, however, without specific written consent.) I understand that if I do not wish to have photographs or video used for such publications that I must provide written notification to the Office for Youth and Young Adult Ministry. I understand that the Office has no control over the use of photographs or video taken by media that may be covering the event. I hereby acknowledge that the above information is true and accurate. By signing below I grant consent for  :                                            to participate in this youth event. In signing this document, I (Youth),                                                        as a participant in a Diocesan youth event, understand and agree to abide by the Diocese of Harrisburg Office for Youth and Young Adult Ministry Code of Conduct for Youth or Adults (if applicable). I,                              as the parent/legal guardian of this youth participant have reviewed the Code of Conduct with my child. I/We also acknowledge that if I/he/she has to return home early for discipline violations, it will be at my/our own expense. Participant Signature Date Parent/ Guardian Signature (if participant is under 18) Date