Covington Catholic Summer Mission Trip Application Form

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April Gilmore
5 years ago
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1 Covington Catholic Summer Mission Trip Application Form Name Adult Student STUDENT MISSIONARY: Grade Level: Parent Name(s) Address: Parent(s) Cell Phone Number: Student cell phone Number: Parent(s) address: Student address: T-shirt size: S M L XL XXL XXXL ADULT MISSIONARY: Affiliation with Covington Catholic: Address: Cell Phone Number: Address: Emergency Contact Name and Number: T-shirt size: S M L XL XXL XXXL Are you willing to drive a carpool of 4-5 students for the week? (Gas will be reimbursed.) Yes No

2 CHILD S PARENTAL CONSENT AND WAIVER OF LIABILITY Child s Name Date of Birth Parent/Guardian s name Home Address Home telephone Business telephone I,, grant permission for my child, to participate in the diocesan/parish/school event described below which requires transportation away from the parish/school. I understand that this activity will take place under the guidance and direction of diocesan/parish/school employees and/or volunteers (hereinafter chaperones ). DATE AND TIME: Departure: June 9 th and Return: June 15 rd 2019_ TYPE OF EVENT Mission Trip DESTINATION: Cumberland, KY MODE OF TRANSPORTATION: _Private Transportation_ In consideration of my child s participation in this event, on behalf of myself, my child, and our heirs, assigns, executors and personal representatives, I release, hold harmless and discharge forever Covington Catholic High School and The Diocese of Covington, respective officers, directors, employees, agents and chaperones from any and all liability, claims, losses, damages, costs or expenses and waive any such claims against any such person or organization arising directly or indirectly from or attributable in any legal way to any action, omission or any other act of any such person or organization in connection with my child s participation in this event. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by my child. I agree on behalf of myself, my child, and our heirs, assigns, executors and personal representatives, to hold harmless and defend Covington Catholic High School and The Diocese of Covington, its respective officers, directors, employees, agents, and chaperones from any claim or damages to any person or property, arising from or on connection with my child s participation in this event or in connection with any illness or injury or the cost of medical treatment of my child, and I agree to compensate Covington Catholic High School and The Diocese of Covington, its respective officers, directors, employees, agents and chaperones for reasonable attorney s fees and expenses arising in connection therewith. I agree that my child will cooperate with the chaperones and that they will not be liable if my child fails to obey the chaperones and that infractions may result in termination of my child s participation. In such event, I further agree to be financially responsible for any costs in other required expenses necessary to transport my child home. Parent/Guardian Signature Date Child s Signature Date

3 CHILD MEDICAL EMERGENCY FORM Name of Child Date of Birth SS# Address IN CASE OF AN EMERGENCY, NOTIFY: Name Relationship; Parent Other Address City State Zip Code Telephone Numbers: Home: ( ) ALLERGIES (Please write YES if applicable) Work: ( ) Hay fever Asthma Sulfa Poison Ivy Penicillin Bee Sting Other PLEASE CHECK IF CHILD HAS ANY OF THE FOLLOWING CONDITIONS: Diabetes Convulsions Bleeding Disorders Contact Lenses Fainting Spells Heart Trouble Prosthesis Migraine Headaches If any of the above are YES, please submit statement of how the child has been treated and with what medications. PLEASE CHECK APPROPRIATE RESPONSE: My child can be given aspirin or Tylenol if needed for minor pain. My child has a medical condition. If Yes, please describe; _ YES NO My child is taking medication. If so, please list name, dosage and Medical condition: YES NO Treatment received for any illness/injury within the last year? If yes, please explain: In case of emergency, I understand that no effort may be made to contact parents or guardian prior to emergency treatment. I hereby give permission to any physician, hospital and/or health care personnel to secure proper treatment for, hospitalize, and to order injections, medication, anesthesia, surgery or other necessary treatment for my child named above. I also give permission to secure proper emergency medical transportation. HEALTH INSURANCE CO. POLICY NO. FAMILY PHYSICIAN FAMILY PHYSICIAN TELEPHONE DATE: (Signature of Parent/Guardian)

4 ADULT WAIVER OF LIABILITY Name Date of Birth Home Address Home telephone Business telephone DATE AND TIME: Departure: June 9 th and Return: June 15 rd 2019 TYPE OF EVENT Mission Trip DESTINATION: Cumberland, KY MODE OF TRANSPORTATION: Private Transportation I release, hold harmless and discharge forever, Covington Catholic High School and The Diocese of Covington, its respective officers, directors, employees, agents and chaperones from any and all liability, claims, losses, damages, costs or expenses and waive any such claims against any such person or organization arising directly or indirectly from or attributable in any legal way to any action, omission or any other act of any such person or organization in connection with my participation in this event. I remain legally responsible for my personal actions. I agree on behalf of my heirs, assigns, executors and personal representatives, to hold harmless and defend Covington Catholic High School and The Diocese of Covington, its respective officers, directors, employees, agents, and chaperones from any claim or damages to any person or property, arising from my participation in this event or in connection with any illness or injury or the cost of medical treatment of mine, and I agree to compensate Covington Catholic High School and The Diocese of Covington, its respective officers, directors, employees, agents and chaperones for reasonable attorney s fees and expenses arising in connection therewith. Signature Date Please print your name:

5 ADULT MEDICAL EMERGENCY FORM Name Date of Birth SS# Address IN CASE OF AN EMERGENCY, NOTIFY: Name Relationship; Address City State Zip Code Telephone Numbers: Home: ( ) ALLERGIES (Please write YES if applicable) Hay fever Asthma Sulfa Poison Ivy Penicillin Bee Sting Other PLEASE CHECK IF HAVE HAD ANY OF THE FOLLOWING CONDITIONS: Diabetes Convulsions Bleeding Disorders Contact Lenses Work: ( ) Fainting Spells Heart Trouble Prosthesis Migraine Headaches If any of the above are YES, please submit statement of how this has been treated and with what medications. PLEASE CHECK APPROPRIATE RESPONSE: YES NO YES NO I can be given aspirin or Tylenol if needed for minor pain. I have a medical condition. If Yes, please describe; _ I am taking medication. If so, please list name, dosage and Medical condition: Treatment received for any illness/injury within the last year? If yes, please explain: I hereby give permission to any physician, hospital and/or health care personnel to secure proper treatment for hospitalize, and to order injections, medication, anesthesia, surgery or other necessary treatment. I also give permission to secure proper emergency medical transportation. HEALTH INSURANCE CO. POLICY NO. FAMILY PHYSICIAN FAMILY PHYSICIAN TELEPHONE (Signature) DATE:

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER. Participant s name: Birth date: Gender: Male / Female (Circle One) Parent or guardian s name

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER Participant s name: Birth date: Gender: Male / Female (Circle One) Parent/Guardian s name: Home address: Home phone: Cell phone: Work phone: I, grant