Next Level Participation Waiver

Youth/Participant Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Cell Phone Number - only list if ok to text* youth Please enter a phone number.

*All communication directly with the youth will include 2 adults and be monitored by the parish.

Gender REQUIRED Male Female Please fill out this field.

Parent/Guardian Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Home Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Consent and Liability Waiver

I, parent or guardian, grant permission for my child, to participate in these parish/school events, that may require transportation to a location away from the parish/school site. This activity will take place under the guidance and direction of parish/school employees and/or volunteers from Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration.

I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“participant”). I understand that my child is required to comply with the Code of Conduct provided by the parish/school while participating in the event. I understand and agree that if my child violates the Code of Conduct he/she may be required to be transported home at my expense.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold
harmless and defend Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration, its officers, directors, employees, coaches, and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter “Releasees”), from any claims, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage.

I Agree Please select this field.

Good Health Statement

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.

Consent Agreement - CR REQUIRED Yes, I agree. No, I don't agree. Please note that this will disqualify your child from participation. Please fill out this field.

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 the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Family Doctor Name REQUIRED Please fill out this field. Please enter valid data.

Family Doctor Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.

Health Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.

Other Medical Treatment

In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Saint Paul and Minneapolis, chaperones, or representatives associated with the activity, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called as soon as it is reasonably possible.

*Check only if you want a call as soon as reasonably possible. Please call as soon as reasonably possible.

Medications (Must choose 1 of 2 options)

Option 1: Check only if child is taking medication and bringing.

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 the child takes such medications, including dosage and frequency of dosage, are as follows:
List of medication with name, dosage, and frequency: Please enter valid data.
*Check only if child is taking medication and bringing. I approve of the above mentioned medications.

Option 2: Check only if child is NOT taking medication.

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
*Check only if child is NOT taking medication. I do not approve of medications being administered.

Check only if you grant permission for non-prescription medication to be given.

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.
*Check only if you grant permission for non-prescription medication to be given. I approve of non-prescription medications be given.
Specific Medical Information
The parish/school will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): Please enter valid data.

Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.

Does child have a medically prescribed diet? Please enter valid data.

Does child have any physical limitations? Please enter valid data.

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? Yes No

If so, list date and disease or condition: Please enter valid data.

You should be aware of these special medical conditions of my child: Please enter valid data.

Electronic Release Forms

Authorization, Consent and Release for use of Visual Likeness and Original Works of MINORS

I grant the following rights to Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis:

1. The right to use all photographs, pictures, portraits, vocal sounds, appearances/likenesses, video and performances (hereinafter collectively known as “image”) of My Child in the possession of Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis;

2. The right to use, reproduce, publish, exhibit, distribute, and transmit the image of My Child individually or in conjunction with other images or printed matter in the production of brochures, slides, motion pictures, broadcasts (radio, television, and other social and digital media), audio or video files, recordings, still photography, CD-Rom and any other manner of media now known or later developed;

3. The right to use, reproduce, publish, exhibit, distribute, and transmit the image of My Child individually or in conjunction with other images or printed matter on Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis’s Internet websites. No home address or phone number will be published;

4. The right to record, reproduce, amplify, edit, and simulate My Child’s image and all sound effects produced;

5. The right to copyright, in the name of Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis, works that contain the image of My Child;

6. The right to use and publish for general communications, advertising, commercial or publicity purposes, or for any other lawful purpose whatsoever My Child’s original work; and

7. The right to assign the above-mentioned rights to third parties without notice to me.

I understand that the video files, still photos, or other media incorporating the image of My Child will become the property of Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis. I hereby waive the right to inspect or approve the image or any finished materials that incorporate the image.

I understand and agree that no compensation will be provided, now or in the future, in connection with the use of My Child’s image or My Child’s original work.

I hereby release, discharge, and agree to indemnify and hold harmless Presentation, Saint John’s of Little Canada, St. Pius X, Transfiguration, the Archdiocese of Saint Paul and Minneapolis, and their agents, employees and assigns from any and all claims, demands, right, and causes of action of whatever kind that I or My Child have or may have or may arise by reason of this authorization and from the use of My Child’s image and original work, including but not limited to, all claims for libel and invasion of privacy.

This consent regarding My Child’s likeness and original work is valid until such time as I choose to rescind this authorization and consent. If I choose to rescind this authorization and consent, I agree that I will inform Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis in writing and that my rescission will not take effect until it is received by Presentation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis. I understand and acknowledge that it may not be possible to recall any work or photos that have been published prior to receipt of my written rescission.

I hereby authorize and consent that Presenation, Saint John’s of Little Canada, St. Pius X and Transfiguration and the Archdiocese of Saint Paul and Minneapolis have the right to use My Child’s name in connection with their educational, promotional, fund-raising activities, or for any other legitimate purpose.

I HAVE READ THE ABOVE AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESES AND ORIGINAL WORKS, ITS DISCLOSURES, AUTHORIZATIONS, AND RELEASES. I UNDERSTAND AND AGREE I HAVE HAD THE OPPORTUNITY TO CONSIDER THE TERMS AND UNDERSTAND THEM. BY SELECTING “YES, I AGREE”, I UNDERSTAND AND AGREE I AM VOLUNTARILY ACCEPTING THESE PROVISIONS WITH FULL KNOWLEDGE OF THE SIGNIFICANCE.

Consent Agreement - CO REQUIRED Yes, I agree. No, I don't agree. Please fill out this field.

Final Agreement and Signature

By my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By my signature below as guardian/participant, I acknowledge and agree to the conditions above.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Full Name typed for signature REQUIRED Please fill out this field. Please enter valid data.

By providing my full name, I agree that it will be the electronic representation of my signature for all purposes when I use it on documents, including legally binding contracts - just the same as a pen-and-paper signature.

Today's Date REQUIRED Please fill out this field. Please enter a date.

Church of St. Pius X

White Bear Lake, MN

Next Level Participation Waiver

Parish Office Hours: 8:30 am - 4:00 pm M-Th 8:30-Noon Fri	Tel 651-429-5337 Fax 651-429-5339
For emergency number, dial parish office (651-429-5337) and press 7.	Staff Directory
Please call the Emergency number only in cases of an accident or last rites in danger of death. Otherwise, call the Parish Office to schedule a visit.	REPORT ABUSE