Adult Release Form

PARTICIPANT INFORMATION
Name
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Address
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Day Phone --
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Evening Phone --
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Parish/School & City
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Emergency Contact Name
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Emergency Contact Phone --
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PHYSICIAN & HEALTH INSURANCE INFORMATION
Family Physician
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Family Physician Phone --
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Family Health Insurance Co.
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Policy No. (Individual)
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(Group)
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Please list any medication that you may have an allergy to and/or any health problems a physician would need to know in treating you.
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MEDICAL AUTHORIZATION & RELEASE OF INFORMATION
In the event of injury or illness I hereby give my permission to Jerry White, Director of Youth Ministry, employee of the Diocese of Charleston, to authorize transportation for me to a medical facility for any necessary medical treatment. I agree that in case of injury I will apply my hospitalization and/of accident insurance toward the payment of the expenses incurred. I give my permission to medical personnel to share information with my parish youth minister or Jerry White, Director of Youth Ministry, in the event of injury or illness.
Signature Required
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RELEASE AND INDEMNIFICATION
I hereby release the Diocese of Charleston, their agents, successors, legal representatives and its employees from any liability for any injury to myself as a result of my participation in the Diocesan event, and I agree to indemnify and save the Diocese harmless for any costs or expenses it may incur as a result of my participation.
Signature Required
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CODE OF BEHAVIOR
Participation in the Conference is a privilege and not a right. Each adult must attend all scheduled activities. The behavior of all (youth & adults) must reflect Christian values. The Sponsoring Adult must stay at the entire event and is responsible at all time for his/her youth. Each parish, through the sponsoring adult, will take full responsibility for any damage done by their group. Drugs/Alcohol are not permitted. The Diocesan staff reserves the right to ask any participant to leave at the participant's own expense. I have read and agree to uphold the above "Code of Behavior".
Signature Required
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DIOCESE OF CHARLESTON OFFICE OF YOUTH/YA MINSTRY
It is the policy of the Office of Youth Ministry of the Diocese of Charleston to require a signed affidavit, from ALL ADULT CHAPERONES at overnight activities, testifying that they have never been charged with or convicted of sexual abuse. This is for the protection of our youth as well as you the adult.
I,
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chaperone for _________ parish,
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have never been the subject of an investigation involving an allegation of sexual abuse.
Signature Required
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