DIOCESE OF OAKLAND
CATHOLIC YOUTH
ORGANIZATION (CYO)
PARENTAL
PERMISSION, HEALTH AUTHORIZATION, RELEASE FORM
THERE MUST BE
A COPY OF THIS FORM AT ALL CYO ACTIVITIES
OChild's Name
_____________________________ Parish __________________________
Address ___________________________________
Phone __________________________
(street,
city, zip)
School
__________________________________Grade __________ Birth Date _________
O Parent/Guardians Name
___________________________Home Phone _______________
Address ___________________________________
Work Phone _____________________
(street, city, zip)
Pager or other Number
________________________________________________________
O IN CASE OF EMERGENCY,
NOTIFY PERSON OTHER THAN PARENT/GUARDIAN:
Name
_________________________________________ Phone ______________________
HEALTH AND MEDICAL INFORMATION
O Family Physician __________________________ Address ___________________________
Phone ____________________________
O Medical Plan _____________________________ Plan Number _______________________
O Do you authorize the adult leader to
authorize medical treatment for your child in an emergency, as considered
necessary by the attending physician? Yes No
State any reasons why you do
not want medical care given to your child in an emergency: _____
____________________________________________________________________________
O List all conditions (such as allergies,
seizures) for which your child requires ongoing medication and state the type
of medication given: ______________________________________________
_____________________________________________________________________________
Has your child had
difficulty with the following (circle all that apply):
Asthma Fainting Spells Convulsions Diabetes Heart
Eyes Ears
Nose Throat Lungs Digestion
Menstrual Problems Other
__________________________________
List any physical
restriction or restriction for any sport activity on the basis of medical
condition:
_____________________________________________________________________________
State the date of your
child's last physical examination: _________________________________
IT IS STRONGLY RECOMMENDED THAT EACH CHILD HAVE A PHYSICAL EXAMINATION PRIOR TO PARTICIPATION IN ANY SPORTS ACTIVITY.
(COMPLETE BACK OF FORM)
Parental Permission and Acknowledgement of
Conditions for Participation inProgram
1. I/we, parent or authorized guardian of the
child named above give permission for his/her participation in (circle all that apply):
® basketball cross country softball track &
field volleyball cheerleading and all related
activities, including but not limited to transportation to and from games or
practice sessions.
2. I/we agree to direct my/our child to cooperate and comply with
reasonable directions and instructions from CYO staff or adult volunteer
leaders (coaches).
3. I/we agree to be responsible for ail medical expenses relating to
injury of my/our child as a result of his/her participation in any sport
activity, whether or not caused by the
negligence of parish, school, or CYO program employees, agents or volunteers or
other participants.
4. I/we understand that children competing in athletic and
recreational sports programs risk injury to the body, psyche or property damage
to themselves and others. Such injuries
can be caused by teammates, other persons or accidentally or intentionally self
inflicted, faulty equipment or facilities, conditions of recreational
facilities or the schools or parishes where sports activities are held, vehicle
accidents while in transport or through the activity itself. Protective equipment used in a sports activity
is not a safeguard against injury.
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
AGREEMENT
In consideration for being
permitted to participate in the sports activities of CYO, use the equipment
provided and to enter the premises or facilities of the Diocese of Oakland
(Diocese) for any purpose including observation and participation in
activities, the parent or guardian for him or herself and any successors in
interest and on behalf of the minor child agrees:
1. To release, waive,
discharge and promise not to sue the Diocese of Oakland, and its affiliated
entities, its officers, directors, employees, agents and volunteers (hereafter
referred to as "Releasees") from all liability for any loss or
damage, and any claim or demands therefor on account of serious or mortal
injury to the body, injury to psyche or property of the minor child, or
undersigned parent or guardian, whether caused by negligence or other conduct
by the Releasees while the minor child, parent or guardian is participating in
CYO sports activities or in, upon or about the premises of the Diocese or any
of its facilities or equipment.
2. To indemnify and hold
harmless the Releasees from any loss, liability, damage or cost it may incur
due to the presence of the minor child, parent or guardian in, upon or about
the premises of the Diocese, its facilities or equipment, or while
participating in any CYO sports activities whether caused by the negligence of
Releasees or otherwise.
3. That the parent or
guardian has read this Agreement, voluntarily signs the Agreement and that no
oral representations, statements or inducements apart from the contents of this
written Agreement have been made.
I have read this Agreement
and understand everything written above.
Signature of Parent or
Guardian_______________________ Date_________________
Signature of Parent or
Guardian _______________________ Date_________________