Parent Guardian Consent Form.pdf - St. Peter's Seminary

St. Peter’s Institute
for Catholic Formation
Parent / Guardian Consent Form and Liability Waiver
Participant’s Name: ___________________________________________ Birth Date: ___________________________
Provincial Health Card Number: _____________________________________________ Expiry Date: _____________
Family Doctor: ______________________________________________ Phone: _______________________________
Parent / Guardian’s Name: ___________________________________________________________________________
Home Address: ____________________________________________________________________________________
Home Phone: ______________________________________ Cell Phone: ____________________________________
I, ________________________________ grant permission for my child, __________________________________ to
participate in the Festival of Faith – October 17, 2009 at Brescia University College, London, Ontario. This event will
take place under the guidance of St. Peter’s Institute for Catholic Formation.
Event Description:
Festival of Faith: 2009 – Celebrate the Living Word
Brescia University College
1285 Western Road
London, ON N6G 1H2
Begins: 8:30 a.m. Ends: 4:00 p.m.
For more info: www.spicf.ca
As a parent and / or guardian, I remain legally responsible for any personal actions taken by the above named participant.
I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St.
Peter’s Institute for Catholic Formation, its employees and agents, chaperones, or representatives associated with any
illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate St.
Peter’s Institute for Catholic Formation, 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 a claim arises from the negligence of St. Peter’s Institute for Catholic Formation.
Initial / 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. (Of the following statements pertaining to medical matters, initial only those that
are applicable.)
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 hospital or doctor. In
the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name and Relationship: _____________________________________________________________________________
Home Phone: ______________________________________ Cell Phone: ____________________________________
Signature: ____________________________________________________ Date: ______________________________

St. Peter’s Institute
for Catholic Formation
Other Medical Treatment: In the event it comes to the attention of St. Peter’s Institute for Catholic Formation, its officers,
directors and representatives associated with the activity, that my child becomes ill with symptoms such as headache,
vomiting, sore throat, fever, diarrhea, I want to be contacted. Initial / Date: ________________
Medications: My child is taking medication at present. My child will bring all such medication necessary, and such
medications will be well labelled. Names of medications and concise directions for seeing that the child takes such
medications, including dosage and frequency of dosage, are as follows:
__________________________________________________________________________________________________
_____________________________________________________________________ Initial / Date: ________________
No medications or any type, whether prescription or non-prescription, may be administered to my child unless the
situation is life-threatening and emergency treatment is required. Initial / Date: ________________
I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen,
throat lozenges, cough syrup) to be given to my child, if deemed appropriate. Initial / Date: ________________
Specific Medical Information: St. Peter’s Institute for Catholic Formation will take reasonable care to see that the
following information will be held in confidence.
• Allergic reactions to: medications, foods, plants, insects, etc.: _________________________________________
• Immunizations: date of last tetanus / diphtheria immunization: ________________________________________
• Does child have a medically prescribed diet? ______________________________________________________
• Any physical limitations? _____________________________________________________________________
• Has your child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox,
etc.? _______________________________________________________________________________________
• You should be aware of these special medical conditions of my child: ___________________________________
___________________________________________________________________________________________
Administrative Matters: Throughout the Festival of Faith – Family Day experience, there will be opportunities for
photographs to be taken that have the potential to be used in St. Peter’s Institute for Catholic Formation and / or Diocese
of London publications and / or websites. There may be reasons why some families do not want their child’s photograph
displayed. Your approval will apply to photographs taken from the time they arrive until their departure from the Festival
of Faith event site on Saturday, October 17, 2009.
I give permission that photographs of the person named above may be displayed.
I request that photographs of the person named above NOT be displayed.
Signature: ___________________________________________________ Date: _______________________________
Would you like to receive additional information regarding diocesan events and opportunities for your young person?
Yes, please send information regarding diocesan events for my young person.
No, thank you.
1040 Waterloo Street North, London, Ontario, Canada
Phone: (519) 432-1824 ext. 281 • Fax: (519) 432-5621 • www.spicf.ca