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By filling out this form, you will be elligible to attend this year's March for Life. If not, you will not be able to attend.

Dear Parent or Legal Guardian:

Your son/daughter is eligible to participate in a school-spon activity requiring transportation to a location away from the parish/school building. 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: 2020 March for Life & Life is Very Good Rally
Destination: Springhill Suites Marriott, Fairfax, VA, for the Youth Pilgrimage & Life Is Very Good Rally
Dates: January 23-24, 2020
Depature Location, Date, and Time: Greensburg Central Catholic High School at 1PM
Student Cost: $50/$75

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 the school/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 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 2020 March for Life Youth Pilgrimage and Life is Very Good Rally 
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*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Grace*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Grace*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Grace*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Grace*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Grace*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Grace*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Grace*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Grace*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Grace*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Grace*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Medical Information

Medications currently taken (prescription and non-prescription) and include dosage

Any medical concerns that the Diocesan staff and medical personnel need to be aware of? Please include any allergies. (Please leave blank if there are no issues)
Can this person be given benedryl by the medical coordinator?*
No
Yes
Can this person be given acetaminophen by the medical coordinator?*
No
Yes
Can this person be given ibuprofen by the medical coordinator?*
No
Yes
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Grace*
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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