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By filling out this form, you will be elligible to attend the National Catholic Youth Conference. Additional Waviers are also required.

Dear Parent or Legal Guardian:


Your son/daughter is eligible to participate in a diocesan sponsored activity offsite. This activity will take place under the guidance and supervision of employees from the Diocese of Greensburg. For this event youth must be in grades 9-12. A brief description of the activity follows:

Name of Event:National Catholic Youth Conference
Destination: Indianapolis, IN
Dates: November 20-24, 2019
Time:: 1:00 PM (Wednesday) to 6:00 AM (Sunday)

If you would like your child to participate in this event, please complete, sign, and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student.

I hereby consent to participation by my child in the event described above. I understand that this event will take place away from parish grounds and that my child will be under the supervision of the designated school/parish employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.

Photographic Release:
I hereby grant to the Diocese of Greensburg, Pennsylvania, and its respective licensees, successors and assigns, the right and permission, with respect to those photographs taken of me or the minor named below on whose behalf I am signing, and with respect to any printed or electronic matter in connection therewith, to do the following:
1. To include such photographs on the Diocese of Greensburg website, Diocese of Greensburg Social Media Sites, and the Catholic Accent
2. To use my name, or the name of the minor on whose behalf I am signing, in connection with the foregoing.

I hereby release, discharge and agree to indemnify and hold harmless the Diocese of Greensburg and its legal representatives, licensees, successor and assigns, from all claims and demands whatsoever arising out of or in connection with the foregoing, and waive any right to inspect or approve the same.

Parent/Guardian Consent/Release:
We, the parents/guardians of (student name) do hereby give our permission for him/her to attend the National Catholic Youth Conference on November 20-24, 2019.

We do hereby release and forever discharge the Diocese of Greensburg and designated chaperones from any/all actions or suits in law or equity which we might hereafter have by reasons of injuries sustained by our son/daughter participating in the above mentioned activity. In case of emergency, we give permission for our child to be treated at a hospital and/or by a medical doctor.

Parent/Guardian

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medical Information

Physician

Physician Number

If required, my child will bring all necessary medications in original, labeled containers. Names of medications and concise directions for seeing that the child takes such medications are as follows:
Medication Instructions
My child may self-administer prescription medication/equipment and carry their own medication/equipment with them throughout the event.
My child may NOT self-administer prescription medication. I authorize selected personnel to administer the indicated medication, or to use the equimpent or machinery as prescribed by my child's health care provider.
Can this person be given any of the following medicines if deemed necessary by the medical staff or if requested by the person?
Acetaminophin (Tylenol)
Ibuprofen (Advil)
Benedryl
Tums
Pepto Bismol

Any medical concerns or health/social issues that the Diocesan staff and medical personnel need to be aware of so that we can better serve your child?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Additional Information
Grade*
T-shirt Size*
Zip Hoodie Size (unisex)*

Cell Phone Number of Participant

Church *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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