Registration/Consent Form | St. Joseph Catholic Club

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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*

Participant's Information

Parent/Guardian's Information

Agreement

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