Registration/Consent Form – St. Joseph Catholic Club

DIOCESE OF HARRISBURG OFFICE FOR YOUTH AND YOUNG ADULT MINISTRY PARENTAL PERMISSION AND CONSENT TO TREAT

Participant's Information

Participant's Name*

First Last

Birth Date*

Age*

Grade*

Address*

Street Address City State ZIP Code

Parish

School*

Parent/Guardian's Information

Parent/Guardian's Name*

First Last

Address (if different than participant)

Street Address City State ZIP Code

Email Address*

Primary Phone*

Secondary Phone

Agreement

I,

Name of parent or guardian*

grant permission for

Participant's Name*

to participate in the St. Joe Softball Program.

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. I understand and have been informed that taking part in this youth trip or event involves the risk of injury.

I hereby grant consent for the coach, chaperone, and/or adult volunteer under whose auspices the program is conducted, to secure all necessary emergency medical care and/or treatment that may be necessary for my child during the entire youth trip/event including any necessary transportation, if provided by the coach, chaperone, or adult volunteer. I release and hold harmless any said coach, chaperone, or adult volunteer, from any liability, who in good faith is placed in a position requiring decisions to be made for emergency care or medical treatment of the above-named young person. In case of accident, injury or loss, neither my family nor I will hold the diocese, the parish, the place where the event is conducted, the group sponsoring the event, nor any person or affiliate organization associated with the event responsible or liable.

In the event of an emergency, if you are unable to reach me at the above number, contact:

Name*

First Last

Relationship to Participant*

Primary Phone*

Secondary Phone

Family Physician*

Phone*

Allergic reactions (medications, food, insects, etc)*

Medication(s) currently being taken*

My child has special medical/mental conditions*

Yes
No

If Yes, please describe below

Insurance Company*

Policy Number*

Signature*

Date*

Relationship to Participant*