VBS – Our Lady of Light

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PRINT AND COMPLETE THIS FORM AND RETURN WITH PAYMENT. If unable to print pick up a form at Parish Office

PARENTAL / GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Participant’s Name ______________________________

Date of Birth ___________________________ Male ___ Female ___ Parent / Guardian Name ____________________________________

Home Address _____________________________________

Contact Phone ____________________________________ I, _________________________________________, grant permission for my child, __________________ to participate in this parish event ( Vacation Bible School). This activity will take place under the guidance and direction of parish employees and / or volunteers from OUR LADY OF LIGHT.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend OUR LADY OF LIGHT its officers, directors, Name of Parish Employees and agents, and the Diocese of San Diego, its employees and agents, chaperones or representatives associated with the event, from any claim arising from or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Diocese of San Diego, its employees and agents and chaperones or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.

Signature ________________________ Date: _______________

MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name & relationship: ___________________________________ Phone:_______________

Name & relationship: ___________________________________Phone: ______________

Medications:

Is your child currently taking any medication(s)? Yes ___ No ___ If “yes,” please list medication(s) and reason for taking medication(s).

_______________________________________________________________________________________________________________________________

Is your child allergic to any medication(s)? Yes ___ No ___ If “yes,” please list medication(s). ______________________________________________________________________________________________________________________________

Does your child have any special medical condition(s); (i.e., allergies, physical limitations, anxiety, fainting, or any condition you would like us to be aware of? Yes ___ No ___ If “yes,” please explain. __________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature ________________________ Date: _______________

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