Consent Form and Liability Waiver - Diocese of London

1070 Waterloo StreetLondon, Ontario N6A 3Y2519-433-0658Fax: 519-433-0011dmoynihan@dol.cawww.dol.caParent/Guardian Consent Form and Liability WaiverParticipant’s Name:______________________________________ Birth Date:___________________Parent/Guardian’s Name: _____________________________________________________________Home Address: _____________________________________________________________________Home Phone: _____________________ Daytime Phone: ____________________________________I, ___________________________ grant permission for my child, _________________ to participate inSpirit Days, October 13 th or October 20 th , 2012.Event Description:Spirit DaysSt. Mary’s Catholic Secondary School431 Juliana DriveWoodstock, ONOctober 13 th , 2012 October 20 th , 2012Ursuline College (The Pines)85 Grand Ave. WestChatham, ONPick up: Holy Trinity Parish904 Dundas StreetWoodstock, ONPick up: St. Agnes Parish52 Croydon StreetChatham, ONArrival at 9:30 a.m. and departure at 3:30 p.m.Transportation to be organized by participants and their chaperones.As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the abovenamed participant.I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless anddefend ___________________ parish, its officers, directors, employees and the Diocese of London, itsemployees and agents, chaperones, or representatives associated with the event, from any claim arising from orin connection with my child attending the event or in connection with any illness or injury (including death) orcost of medical treatment in connection therewith unless such a claim arises from the negligence of theparish/diocese.Signature: ________________________________________ Date: ____________________Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assumeall responsibility for the health of my child. (Of the following statements pertaining to medical matters, signonly those that are applicable.)Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my childto a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment

y hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers,contact:Name: & Relationship:______________________________________________________________________Phone: _____________________________ Family Doctor: ________________Phone:__________________Provincial Health Number: __________________________________ Date:___________________________Signature:_________________________________ Date: ________________________Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agentsand the Diocese of London, chaperones, or representatives associated with the activity, that my child becomesill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (withphone charges revered to myself).Signature:_________________________________ Date: ________________________Medications: My child is taking medication at present. My child will bring all such medications necessary,and such medications will be well-labeled. Names of medications and concise directions for seeing that thechild takes such medications, including dosage and frequency of dosage, are as follows:________________________________________________________________________________________Signature:_________________________________ Date: ________________________No medications of any type, whether prescription or non-prescription, may be administered to my child unlessthe situation is life-threatening and emergency treatment is required.Signature:_________________________________ Date: ________________________I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen oribuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.Signature:_________________________________ Date: ________________________Specific Medical Information: The Diocese of London and parish will take reasonable care to see that thefollowing information will be held in confidence.Allergic reactions, 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, chickenpox etc? ________________________________________________________________________________You should be aware of these special medical conditions of my child:________________________________________________________________________________________________________________________Administrative Matters: The Diocese of London would like permission to use photos of camp participants inour publications and web site. It is understood that the names of campers will be withheld.☐ I give permission for photographs of the person named above to be used in Diocese of Londonpublications and web site.Signature:__________________________________Date________________________________