Jr High Herd Consent Form, Liability Waiver and Health Form
This is our general consent and health form for all youth ministry events. WE MUST HAVE THIS FORM ON FILE FOR YOUR CHILD TO ATTEND ANY YOUTH MINISTRY EVENT.  Parents/guardians will fill this out once a year as we also have a consent per event as part of our sign-up system.  Should you have any questions or comments, please contact Mike Raymer, Director of Youth Ministry in the Parish office at (502) 448-2122, Ext 231.
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Student Name *
Student Birth Date *
MM
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DD
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YYYY
Grade / School *
Parent/Guardian's Name *
Parent/Guardian Phone Number *
Home Address (Street/City/State/Zipcode) *
2nd Parent/Guardian's Name / Phone Number *
In the event of an emergency and if you are unable to reach me at the above numbers, please contact this person. (please include the name of the person, phone number, and relationship to participant): *
Insurance Company and Policy Number *
Does your child have any allergies and if so, what are they? *
Does your child have any illnesses or mental or physical limitations we should be aware of and if so, what are they? *
I give my permission to administer over the counter medication: (Advil, Tylenol, cold medicine, etc) *
Liability Release
By signing my name in the box below, I grant permission for my child to participate in all youth ministry activities sponsored by the St. Lawrence Youth Ministry Office (1925 Lewiston Drive. Louisville, KY 40216). In the event of an emergency, I authorize an adult, in whose care the minor has been entrusted, to consent to an X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or licensed dentist on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital I agree that I will be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume responsibility for transportation and/or incurred transportation costs. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the St. Lawrence Parish Youth Ministry Office. I will not hold The Archdiocese of Louisville, St. Lawrence Parish, Youth Ministry Coordinators, or chaperones associated with the event responsible in the event of injury. *
Photo and Media Release
By typing my name in the box below, I hereby grant my consent to use and release to: The Catholic Parish of St. Lawrence the use of my child’s likeness, whether in still, motion pictures, audio, or digital video recording, photograph, and/or other reproduction of me or my child, including voice and features, with or without names, of any promotional purposes involving the parish or program, news feature stories or other media or other purposes whatsoever, except for the endorsement of any commercial products. I further agree that the Catholic Parish of St. Lawrence may use or cause to be used, these items for any and all broadcasts, publications, social media, reproductions, or website, without limitation or reservation of any fee.
Movie Rating Release
I give permission for my child to watch movies with the following ratings.
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