Fillable ADW PARENTAL/GUARDIAN CONSENT FORM, RELEASE, AND LIABILITY WAIVER

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ADW PARENTAL/GUARDIAN CONSENT FORM, RELEASE, AND LIABILITY WAIVER

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ADW PARENTAL/GUARDIAN CONSENT FORM, RELEASE,
AND LIABILITY WAIVER – INCLUDING HIGH-RISK AND
ADVENTURE ACTIVITIES
Southern Maryland ROOTS Pilgrimage, September 24, 2022
1
Participant’s name: _________________________________ Birth date: ______________
Sex: ____________ Parent/Guardian’s name: _____________________________________
Home address: _________________________________________________________
Home phone: __________________________ Cell phone: __________________________
I, ______________________ grant permission for my child, _________________________
Parent or guardian’s name Child’s name
to participate in this activity or event that requires transportation to a location away from the parish site. Except
for activities conducted through a third-party provider, this activity will take place under the guidance and
direction of parish employees and/or volunteers from Our Lady of the Wayside, Holy Angels, Sacred Heart, and
St. Francis Xavier Parishes.
A brief description of the activity/event (which may involve high-risk/adventure activities) follows:
Type of activity/event: Southern Maryland ROOTS – The Journey Pilgrimage to St. Clement’s Island
Destination of event: St. Clement’s Island, Colton’s Point, MD
Individual in charge: Theresa Friess
Estimated time of departure and return: 9:00am – 9:00pm
Mode of transportation to and from event: Bus and Boat
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named
minor (“participant”). On behalf of myself and the participant, I hereby fully release, and waive any and all
claims against, the Archdiocese of Washington, its parishes, directors, employees, agents, chaperones, and
representatives associated with the activity/event (collectively, “Archdiocese”), as set forth below in more
detail.
I understand that this activity/event may involve high-risk activities, with an increased risk of personal
injury. I further understand that a separate, location-specific release and liability form(s) (“Location-Specific
Release”) may be required by the third-party provider(s) of the high-risk activities (“Third-Party Provider”). I
agree that it is my obligation to read the Location-Specific Release and carefully consider the risks involved
before signing.
With appreciation of the dangers and risks associated with this activity/event and all related activities, on my
own behalf and on behalf of the participant, I hereby fully and completely release and waive any and all claims,
including—but not limited to—those for personal injury, death, or loss, that may arise against the Archdiocese
of Washington and I hereby further agree that the full scope of the Location-Specific Release’s waiver and
release language shall also encompass any potential claims against the Archdiocese of Washington related to
this activity/event, such that the Archdiocese of Washington is released from any and all claims at least to the
same extent as the Third-Party Provider.
2
ADW PARENTAL/GUARDIAN CONSENT FORM, RELEASE,
AND LIABILITY WAIVER – INCLUDING HIGH-RISK AND
ADVENTURE ACTIVITIES
Southern Maryland ROOTS Pilgrimage, September 24, 2022
Participant’s name: _____________________________________________________
On behalf of myself and on behalf of the participant, I hereby fully and completely release and waive any
claims against the Archdiocese relating to and/or arising out of the activity/event, to the fullest extent allowed
by law.
I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns, to hold harmless and
defend Our Lady of the Wayside, Holy Angels, Sacred Heart, and St. Francis Xavier Catholic Parishes, its
officers, directors, employees and agents, and the Archdiocese of Washington, its employees and agents,
chaperones, and representatives associated with the event, from any claim arising from or in connection with
my child attending the activity/event or in connection with any illness or injury (including death) or cost of
medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and
agents, and the Archdiocese of Washington, its employees and agents and chaperones, or representatives
associated with the event, for reasonable attorneys’ fees and expenses which may incur in any action brought
against one or more of them as a result of such injury or damage.
By signing below, I represent and warrant that I am the parent or legal guardian of the participant and have
authority to sign this consent, release, and waiver.
Signature: ___________________________________________ 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,
sign 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
the 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: __________________
Family Health Plan Carrier: ____________________________ Policy #: ______________________
Signature: _____________________________________________ Date: ____________
Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agents,
and the Archdiocese of Washington, 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 collect
(with phone charges reversed to myself).
Signature: ____________________________________________ Date: ____________
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3
ADW PARENTAL/GUARDIAN CONSENT FORM, RELEASE,
AND LIABILITY WAIVER – INCLUDING HIGH-RISK AND
ADVENTURE ACTIVITIES
Southern Maryland ROOTS Pilgrimage, September 24, 2022
Participant’s name: _____________________________________________________
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 the child
takes such medications, including dosage and frequency of dosage, are as follows:
________________________________________________________________________
Signature: __________________________________________________ Date: _______
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.
I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or
ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.
Signature: _________________________________________________ Date: ________
Specific Medical Information: The parish will take reasonable care to see that the following 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? _______________________________________________
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?
___________________________________________________________________________________
Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox,
etc.? If so, list date and disease or condition:
_____________________________________________________________________________________
You should be aware of these special medical conditions of my child: ___________________________
___________________________________________________________________________________
___________________________________________________________________________________
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ADW PARENTALGUARDIAN CONSENT FORM, RELEASE, AND LIABILITY WAIVER

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Completed 23 May 2022

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