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Liability, Medical and Consent Form

For Individual Parish Use Only

 

Participant Information

Please type your full name.

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Event Information

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Waiver and Release Regarding COVID-19 and Viral Infections


I hereby acknowledge and agree that my participation in this event may expose me to many inherent risks; including but not limited to the potential exposure to viral illnesses such as influenza, COVID-19, SARS and others. I am aware of the recent global pandemic involving viral illnesses and specifically COVID-19. These are serious and dangerous infections, which could cause grave illness and in some cases death.

I assume all risks associated with my participation in the event. I proceed with participating in the event willingly, voluntarily and with full knowledge and appreciation of these risks, which include close and continued contact with others.

I acknowledge my responsibility to communicate any personal circumstances which might conflict with my ability to safely participate; and I acknowledge that I have a duty and responsibility not to participate if I am concerned for my health and safety, or if my own personal condition poses any risks of harm to others.

By signing below, I acknowledge my understanding of all of the above; and I hereby waive, hold harmless and release the Catholic Diocese of Savannah and its leadership, owners, officers, members, representatives, agents, employees, contractors, successors and assigns from and against any claim for personal injury (including death) or illness of any kind arising out of my participation. I hereby also agree to indemnify and defend the Catholic Diocese of Savannah against any third party claim of an injury alleged to have been caused by or as a result of my participation.

I understand that if my current health situation changes, it is my responsibility to notify the event leader.

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Any participant with known exposure to COVID-19 shall not be allowed access to this event until at least fourteen (14) days have elapsed since the last known exposure.

Students may be required to wear face coverings and practice social distancing at specified times.

Medical Matters

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Emergency Medical Treatment
In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical or surgical treatment. In such an event, please contact:

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Medications

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Specific Medical Information

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Code of Conduct and Expectations of All Participants

Each chaperone, participant and Young Adult Helper must agree to these rules. Chaperones, please read carefully as you will be asked to enforce these policies.


Everyone

  • Alcohol, illegal drugs and tobacco are prohibited (NO SMOKING)
  • Weapons are prohibited
  • Dress code:
    Shorts and/or skirts must come to at least the knees
    No low-riding pants
  • Must be spiritually mature whose language, conversation and actions reflect the teachings and moral values of the Catholic Church
  • I understand that I will be expected to remain on-site for the entire time of the event.
  • No refunds will be given.

PHOTO RELEASE FOR INTERNET AND NEWSPAPER: I hereby grant permission for photographs taken of me at this event to appear on one of the communication mediums of my parish/school/organization (bulletin, newsletter, website, etc.) and/or the Catholic Diocese of Savannah (e.g., The Southern Cross or diocesan websites)l. I understand that these images will be used only in relation to these publications and this event. Any other use of said images will require my full written consent.


Participants

  • Participants must be within the age range of the event
  • No cell phones, iPods, or electronic devices

Chaperones

  • Chaperones must be 21+ years of age and in compliance with “Diocese of Savannah’s Safe Environment”
  • Be aware of any significant health issues and pre-existing conditions affecting the members of your group. Any illness or health problems developing during the conference should be reported to the health care staff
  • Avoid situations of being alone with a youth at any time
  • Treat all youth with respect and only discipline members of your own group unless it is an emergency situation. Any concerns about the behavior of youth not under your care should be addressed to the conference staff
  • Chaperones are responsible for their youth at all times
  • Uphold all Chaperone and Participant guidelines

Sign and Submit

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Director of Catholic Education & Superintendent of Catholic Schools

Michelle Kroll
912-201-4122

Director of Youth Ministry

Caroline Ebberwein
912-201-4057

Executive Assistant to the Department of Catholic Education

Nancy Thornock
912-201-4121


Pray for us.