Consent Form

Parent Consent Form

For Western Maryland Regional Youth Events

Please Print or Type:

Event Name/Description: ________________________________________________________

Event Date: ___________ Departure/Begin Time: __________ Return/End Time: __________

Mode of Transportation: _________________________________________________________

Event Contact Person: ________________________________________ Ph: _______________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Name of Participant: _____________________________________ Age: _____ Gender: M / F

Address: __________________________________________________ Ph: _______________

City: ___________________________________ State: ____________ Zip: ______________

Parish: ____________________________________________ Location: _________________

Parent / Guardian Name: _________________________________________________________

Parent / Guardian Phone: ________________________ Wk / Cell: _______________________

Other Emergency Contact: ______________________________ Phone: __________________

Insurance Company: ____________________________________________________________

Primary Insured: _______________________________ Relationship: ____________________

Group/Plan#: ________________________ Policy#: ____________________________

Health Concerns (medication, allergies, limitations?): __________________________________

______________________________________________________________________________

Consent / Waiver / Release:

· I hereby give permission to this youth to attend and participate in activities of the above

named event.

· I hereby give permission for this youth to ride in any vehicle designated by the adult in

whose care this minor has been entrusted while attending and participating in this event.

· I understand the general guidelines of behavior - that the participant must respect and

obey the instructions of the supervising adults and that NO alcohol, tobacco, illegal

drugs, or sexual misconduct will be tolerated at the event - and that the supervising adults

have the right to reasonably enforce the established rules of conduct.

· I will assume all transportation costs for the youth if problems occur during this event

and s/he must be sent home. I will take no civil or legal action against the supervising

adult(s) for the normal care of the minor in their charge.

· I am aware that the Diocese of Maryland Standards of Behavior for Child- & Youth-

Related Programs is available for me to review at www.youth.ang-md.org.

· I understand that every effort will be made to contact me in the event of any accident or

injury to my child. In the event I cannot be reached, I hereby authorize any supervising

adult, in whose care this minor has been entrusted, to consent to whatever medical or

surgical treatment may be necessary or advisable by the physician or nurse treating such

injuries. I understand that I am responsible for the cost of all medical treatment that is

administered to my child.

Signatures

Participant Printed Name: _____________________________________________________

Participant Signature: _____________________________________ Date: ____________

Parent / Guardian Printed Name: _______________________________________________

Parent/Guardian Signature: _________________________________ Date: ____________