SAMPLE PARENT CONSENT FORM PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER PARTICIPANT’S NAME: BIRTH DATE: SEX: PARENT/GUARDIAN'S NAME HOME ADDRESS: HOME PHONE: [BUSINESS PHONE: 1, (name of parent or guardian) + grant permission for my child (name of child) to participate in this parish activity that requires ‘wansportation toa location away from the parish site, This activity will ake place under the guidance and direction ‘of parish employees from (name of parish) ‘A brief description of the activity follows: Type of event or activity; Destination of event or activity: Individual in charge or and responsible:|_ Estimated time of departure and retum: ___ Mode of transportation to and from event: As parent, and/or legal guardian, I remain legally responsible for any personal actions taken by the above named. young person (“participant”), agree on behalf of myself, my child’ other parent ifknown or living (name of parent) amy child named herein, or our heirs, successors, and assigns, to hold harmless and defend (name of parish) its officers, directors and agents, and the Diocese of San Diego, chaperons, or representatives associated with the event with respect to any and all actions, claims or demands that may be made or brought against the parish, its officers, directors and agents, and the Diocese of San Diego, chaperons, or representatives associated with the event, arising from or in connection with my child's attending the ‘event or in connection with any illness oF injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Diocese of San Diego, chaperons, or representative associated with the event for reasonable attorney's fees and expenses arising in connection therewith Signature, Date MEDICAL MATTERS: Thereby warrant that tothe best of my knowledge, my child isin good health, and Tassume all responsibility forthe health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes: (continued on next page)Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child toa hospital for emergency medical or surgical treatment. 1 wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me atthe above numbers, contact: NAME & RELATIONSHIP: PHONE, FAMILY DOCTOR PHONE) FAMILY HEALTH PLAN CARRIER: POLICY NUMBER: 1) Signature. —_——____________ Dats. Other Medical Treatment: In the event itcomes tothe attention of the parish, its officers, directors and agents, and the Diocese of San Diego, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself) 2) Signature Date “Medications. My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows: (Sieg eee 72) ‘No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required. 4) Signature Date Thereby grant permission for nonprescription medication (such as aspirin, throat lozenges, cough syrup) tobe given to my child if deemed advisable 5) Signature Date Special Medical Information: The parish will ake reasonable care to see thatthe following information will be held in confidence.DRIVER INFORMATION SHEET FOR EVENTS OFF PARISH PREMISES DRIVER: Name Date of Birth Address Social Security # Phone # Driver License # Expiration Date VEHICLE TO BE USED: Name of Owner Model ‘Owner Address Vehicle Make Vehicle Year License Plate # Expiration Date Registration Expiration Date If more than one vehicle is to be used, the aforementioned information must be provided for each vehicle. INSURANCE INFORMATION: ‘When using a privately-owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle. Insurance Company Policy # Expiration Date of Policy Liability Limits of Policy Note: The minimal, acceptable liability limit for privately-owned vehicles is $100,000/ $300,000. CERTIFICATION: I certify that the information given on this form is true and correct to the best of my knowl- edge. Tunderstand that as a volunteer driver, I must be 21 year of age or older, possess a valid driver's license, have the proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle used to transport youth. (signature) (date)