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Archdiocese of cincinnati

I, the lawful parent or guardian of (the “child”), give permission for my child to participate in the activity described above and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity. 2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel: (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child. (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical This power of attorney shall lapse automatically upon completion of the activity and related travel. I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes, website and office functions. I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning. I have all the necessary information about activities involved.
Signature of Participant (if 18 or over)
*********************************************************************************** Student’s School *********************************************************************************** Medical Information — Completed by Parent or Guardian — Please Print
Child’s Name
Chronic Conditions (e.g. epilepsy, diabetes, learning disorders) Please  If requested, my child may be given these non-prescription products (circle each approved)
 NO MEDICATION of any type may be given to my child unless the situation is life threatening, *Social Security Number is optional; however, please note that some hospitals WILL NOT treat without it.
*********************************************************************************** ACTIVITY INFORMATION -- Completed by Church Agency - Please Print
One-Time Activity
Church Agency St. Margaret of York
Teens should return this form with their $50 to the parish office where they can pick up their ticket. Tickets will be available for pickup on or after Tuesday, June 25th. Teens may go to the park with their parents permission whenever they like, but teens will not be supervised until they meet at the Drop Zone at 4PM. Teens are responsible for arranging their own transportation to and from this event.



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