Form A: Annual Consent and Release
DIOCESE OF WILMINGTON
PARISH/INSTITUTION ANNUAL PARENTAL CONSENT AND RELEASE FORM
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Email *
Full Name of Child *
Medical Information :  Please provide Family Doctor's name and phone number *
Please provide Family Dentist name and phone number *
Insurance Provider, Policy #, Acct./ID # *
Has the young person ever been seen by a heart specialist for a heart condition? *
Has the young person had a broken bone in the past six (6) months? *
Has the young person had surgery in the past six (6) months? *
Is the young person currently taking prescribed medication(s) that could inhibitstrenuous physical activity? *
Is the young person allergic to bee stings?** *
Does the young person have asthma?** *
Are there any serious medical conditions of which the Youth Minister, Director/Coordinator of Religious Education, Principal/School Nurse should be aware?* *
*If you answered ‘yes’ to any of the above, it is the responsibility of the parent/guardian to check with parish/schoolrepresentatives to ensure those items *ed above will not endanger the young person.**CYM requires that athletes be able to self-administer the epi-pen and/or inhaler without assistance.     Please List:   Current Prescription -  MedicationsMedicinal -AllergiesFood Allergies *
If necessary, the group leader is permitted to administer the following over the counter medications to my child: *
Parent Information has been provided at registration.  You do not need to add it again unless you prefer to.  Name, address, telephone, *
In Case of EmergencyThe following procedures are in place if your child becomes sick or injured, or needs to be sent home for disciplinaryreasons. Calls will be made to the following numbers, in the following order.1. Home2. Cell phones of Mother/Father/Guardian3. Place of Employment for Mother/Father/Guardian4. Ambulance for transportation of child to medical facility (in case of injury). In case of a major injury that requiresimmediate medical attention, an ambulance may be called first.Staff will continue to call the parents or guardians until one is reached. Please note: information on this form will beshared with emergency medical staff. *
Personal Electronic Technology Devices (PTD)All extraneous personally owned technology devices, including, but not limited to, cellular phones, Blackberrys,pagers, beepers, gaming devices, headsets, and other communication devices are for use only during an actual lockdown or emergency. Other devices, including, but not limited to, tablet PCs, mobile presenters, wireless tablets, digitalaudio and video recorders, Palms, Sidekicks, iPods, Kindles, iPads, MP3 players, texting calculators, camera videophones, digital cameras or laptops are to be used only when permission has been granted by an institutional ororganizational employee with the authority to grant such permission. Devices capable of capturing, transmitting, orstoring images or recordings may never be accessed, turned on or operated in restrooms, dressing rooms, or otherareas where there is a reasonable expectation of privacy. To protect the safety and well-being of students, staff andother community member’s personal property and to avoid disruptions to the learning environment; group leaders,teachers, or school personnel reserve the right to confiscate or collect any PTD. The content of any PTD device maybe reviewed by a designated chaperone or official as part of any investigation of policy violation or other suspectedinappropriate, immoral and/or illegal use. If an illegal act is discovered, local law enforcement officials will becontacted. The Catholic Diocese of Wilmington and its parishes and organizations are not responsible for any harm toPTDs, including by not limited to the loss, theft, damage, or destruction of PTDs or any contents therein. *
Permission and Hold HarmlessI hereby give my consent for the above named individual to participate in the above named parish/school youthactivity (ies) during the current program year. I authorize responsible personnel to obtain proper medical treatmentsshould it become necessary. Excluding intentional, deliberately-inflicted and illegally caused injuries, I further agree, inconsideration of the above named parish’s sponsorship of beneficial youth programs, to release the above namedparish, the Catholic Diocese of Wilmington, and all of their employees, directors, administrators, youth ministers andvolunteers from all legal liability for accidental injuries suffered by my child as a result of participation in athleticactivities, or travel to and from any officially sanctioned event. Providing, however, that recourse is reserved to seekdamages, medical and hospital expenses, and court costs for any such accidental injuries to my child incurred duringan officially sanctioned event from any liability insurance carrier within the limits of its liability policy.If I cannot be reached and the parish/school authorities have followed the procedures described, I agree to assume allexpenses for transporting and medically treating this student. I also hereby consent to any treatment, surgery,diagnostic procedures which may be carried out based on the medical judgment of attending physician.I understand that the Diocese of Wilmington and its staff are committed to providing fun, safe, educational experiencesand that diocesan events are conducted in smoke-, alcohol-, and drug-free environments. In light of this, and to helpensure the safety of all concerned, I understand that if my child is in possession of drugs, alcohol, or tobacco products,engages in illegal, immoral, or offensive behaviors, or refuses to follow the directions given by event staff or volunteerswhile participating in this activity, I will be contacted immediately to pick up my child.I understand that promotional pictures (individual and group) may be taken during officially sanctioned events. I givepermission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars,power point, etc.) in highlighting the event. I understand, however, that the above named parish/institution has nocontrol over the use of photograph or film taken by media or private vendors that may be covering events.I affirm that the information above is true and correct and may be shared with school personnel on a “need to know”basis.Signature *
I agree to submit my agreement with this electronic signature.  Please write your name and date: *
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