THE EPISCOPAL DIOCESE OF DALLAS ALL SAINTS Youth (ASY)

Family and Medical Information and Release Form

 

Name: _______________________________ Age: __________________ DOB: ______________

Phone: _______________________________

Address: _________________________________________________________­­­­________________

                                 Street                                              State                         Zip

Mother: ______________________________________ Phone: _____________________________

Father: ______________________________________   Phone: ____________________________

In case of an emergency, notify:   __________________________________________________

Relationship: ___________________________________ Phone: ___________________________

Family Physician: _______________________________ Phone: ___________________________

Family Insurance Co: ____________________________ Policy #: _________________________

Last tetanus booster: _____________________________

Medical Information:

Are you currently, or have you ever experienced a condition which would impact your participation in an EDOD youth activity?________________________________________________________

If yes, please explain and help us know the best course of action or treatment in case of an event:___________________________________________________________________________________

ATTACH ADDITIONAL SHEETS IF NEEDED

Allergies:

Food(s): _________________________________________________________________________________

Drug(s): ____________________________________________________

Insect stings/bites: ______________________, Poison sumac, ivy and/or oak: _____________

Medications (prescription/OTC):

Required during a day event: _____________________________________________________________

Required during an overnight event: ______________________________________________________

May be administered if needed: ___________________________________________________________

Dietary needs or restrictions: _____________________________________________________________

 

I, the undersigned, to hereby verify that the above information is correct and I do hereby release and forever discharge all sponsors and _____________________________ (insert respective parish name) from any and all claims, demands, causes, actions or causes of action, past, present, or future arising out of any damage or injury while participating in a church sponsored youth activity.

 

Please provide a copy of the appropriate insurance card (front and back)

 

Permission for treatment:

My permission is granted for _____________________________ (insert respective parish name), Priest, Youth Minister(s), other staff, or adult volunteer(s) in charge to obtain necessary medical attention in case of sickness or injury to my child _______________________________________________.

 

RELEASE

Effective dates October 1, 2023 to September 30, 2024

The undersigned parent or legal guardian of _________________________________________,
a minor child, does hereby grant permission for the said child to engage in the various activities sponsored by _____________________________ (insert respective parish name) for its Youth Programs including, but not limited to, travel in automobiles, attendance at related group activities, and general participation in any and all activities sponsored by or associated with THE EPISCOPAL DIOCESE OF DALLAS AND _____________________________ (insert respective parish name)

Photo Release

I _______________________________ understand that promotional pictures (individual and group) have been / will be taken during youth events. I DO or DO NOT (circle one) give _____________________________ (insert respective parish name) and its agents permission for my son’s/daughter’s picture to be taken and used for promotional materials (newsletter, web page, promotional signs, etc.)highlighting events. FIRST AND ONLY FIRST NAMES WILL BE USED.
Parent / Guardian Signature: _________________________________ DATE: ______________

Forms can be returned to your leaders at _____________________________

By mail care of ______________________________________________________

Or scanned and e-mailed to: __________________________________

(insert respective parish name, address, and email information)

Or hand delivered.

ALL FORMS WILL BE RETAINED ON FILE IN THE CHURCH OFFICE.

 

RELEASE AND INDEMNITY

Individually and on behalf of said, minor child we hear by release _____________________________ (insert respective parish name), its vestry, wardens, staff, and volunteers (collectively the “Holy Trinity Parties”), from any and all liability for any claims of any nature related or arising out of travel in automobiles, attendance at related group activities, and general participation in any and all activities sponsored by or associated with ASY OR _____________________________ (insert respective parish name). INDIVIDUALLY AND ON BEHALF OF SAID MINOR CHILD WE HEREBY AGREE TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE HOLY TRINITY PARTIES FROM AND AGAINST ANY AND ALL CLAIMS (INCLUDING, WITHOUT LIMITATION, THE AMOUNT OF JUDGMENTS, COURT COSTS, ATTORNEYS FEES, AND AMOUNTS PAID IN SETTLEMENT) ARISING OUT OF OR CONNETION WITH SUCH ACTIVITIES. THE RIGHT OF INDEMNIFICATION PROVIDED IN THIS DOCUMENT SHALL APPLY EVEN IF THE CLAIM ARISES I WHOLE OR IN PART FROM THE NEGLIGENCE OF ANY ASCENSION PARTY, INCLUDING ANY _____________________________ (insert respective parish name) OWN NEGLIGENCE, WHETHER SUCH CONDUCT IS THE SOLE, JOINT, CONCURRING ACTIVE OR PASSIVE CAUSE OF ANY CLAIMS, LOSSES, OR DAMAGES.

 

 

Dated this ______ day of _____________, 20______ in the state of ______________,

County of _______________.

 

Signature: ___________________________________,

Relationship: ________________________________

 

On this ______ day of _____________, 20______ personally known by me and in my presence, executed the within and foregoing Family and Medical Information and Release Form. Witness my hand and official seal.

 

______________________________________

Notary Public

 

My commission expires: __________________