West Side H.O.M.E. Court Open Gyms

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Monday - Friday | June 19 - August 4, 2023

St. Martin de Porres’ Purcell Hall
4300 W. Washington Blvd., Chicago, IL.

Mornings: 10 a.m. - 12:30 p.m. (14 years old & Under)
Afternoons: 1:30 p.m. - 4:00 p.m. (15 years old & Up)

Participant's Name *

Address (Include City, State, Zip Code) *

Date of Birth *

YYYY

Gender *

Female

Male

School *

Grade *

Row 1

Does Participant have any PHYSICAL PROBLEM or ILLNESSES? If YES, please list them here: *

Does Participant take any medications? If YES, please list them here: *

Does Participant have any ALLERGIES (including medicine)? If YES, please list them here. *

Does Participant have Medical Insurance? If YES, please provide Name of Insurance and Policy Number. *

I hereby give permission for my child to participate in the 2023 Westside H.O.M.E. Court Open Gyms (Program) from June 19 – August 4, 2023. I understand that this program includes playing sports, running, jumping, & other skills. There is an inherent risk in playing athletics. Injuries include but are not limited to sprained ankles, muscle pulls, injury to joints, bones, ligaments & tendons, and neck & back injuries. In an effort to make the event run more safely, it is vital that all athletes follow the directions given. I hereby release and indemnify St. Martin de Porres’ Purcell Hall, Maryville Academy, Catholic Youth Office, its Open Gym Program, its staff, it’s volunteers, and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever, from my child's participation in this program. I also authorize and give consent to St. Martin de Porres’ Purcell Hall, Maryville Academy, and Catholic Youth Office (CYO) to photograph or take video images of my child(ren) for educational and/or publicity purposes. (Please provide Name of Parent/Legal Guardian. If Participant is 18 years old or older, please provide your name.)

I agree to hold St. Martin de Porres’ Purcell Hall, Maryville Academy, and Catholic Youth Office (CYO) harmless from any claims of damage or harm regarding the use any such photographs or video images. (Please provide Name of Parent/Legal Guardian. If Participant is 18 years old or older, please provide your name.) *

Date *

YYYY

Cell Number of Parent/Legal Guardian (If you are 18 years old or older, please provide your number). *

Email of Parent/Legal Guardian (If you are 18 years old or older, please provide your email address). *

NAME of EMERGENCY CONTACT (If Parents/Legal Guardian cannot be reached) *

RELATIONSHIP to Participant *

EMERGENCY CONTACT - CELL NUMBER *

ASSUMPTION OF RISK AND WAIVER AND RELEASE OF LIABILITY RELATING TO COMMUNICABLE DISEASES, INCLUDING COVID-19 I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19. I acknowledge and understand that the circumstances regarding COVID-19 are changing from day to day and that, accordingly, the CDC guidelines are regularly modified and updated and I accept full responsibility for familiarizing myself with the most recent updates. The undersigned, in my capacity as parent/legal guardian, hereby acknowledge the health risks and dangers associated with the transmission of the COVID-19 virus, and other communicable diseases, and recognize that exposure to the COVID-19 virus, or other communicable diseases, could occur while my child participates in the Program. As such, and in consideration for the Program, the undersigned, for myself and my minor child enrolled in the Program fully assume all of the risks associated with participation in the Program, including the possibility of COVID-19 community spread. I, AS PARENT AND/OR LEGAL GUARDIAN, HAVE READ AND FULLY UNDERSTAND AND ACKNOWLEDGE THE CONTENTS OF THE RELEASE AND AGREE THAT I AM VOLUNTARILY WAIVING, RELEASING, INDEMNIFYING AND DISCHARGING MARYVILLE ACADEMY AND ITS OFFICERS, DIRECTORS, EMPLOYEES AND VOLUNTEERS FROM ANY AND ALL LIABILITY, DAMAGES, AND EACH AND EVERY ACTION (COLLECTIVELY, “CLAIMS”) BY PARTICIPATION IN AND/OR ASSOCIATED WITH THE PROGRAM INCLUDING, BUT NOT LIMITED TO EXPOSURE OR TRANSMISSION OF THE COVID-19 VIRUS. I represent that I have full authority to sign on behalf of my child and that my signature binds each other person having authority to make decisions on behalf of the child.

MY NAME BELOW IS CONFIRMATION THAT I HAVE READ AND FULLY UNDERSTAND AND ACKNOWLEDGE THE CONTENTS OF THE RELEASE AND AGREE THAT I AM VOLUNTARILY WAIVING, RELEASING, INDEMNIFYING AND DISCHARGING MARYVILLE ACADEMY AND ITS OFFICERS, DIRECTORS, EMPLOYEES AND VOLUNTEERS FROM THE CLAIMS. *

Has Participant been FULLY vaccinated for COVID-19? *

YES

If Yes, provide DATE of FINAL DOSE

YYYY

Name of Parent/Legal Guardian (If 18 years old or older, provide your name). *

Today's Date *

YYYY

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