WAIVER AND RELEASE
For youths (under age 18) and adults =
(age
18 and over)
Parish or School Name: =
; ___________________________________
I hold the Parish, the Diocese, the Daughters of
Charity, and the Vincentian Marian Youth Association of the Province of the
West harmless from any claim of injury, sickness, illness or damage that I =
may
suffer or sustain during the ACTIVITY listed below, with exception to injur=
y of
damages arising out of the sole negligence of the Parish, the Diocese, the
Daughters of Charity, or the Vincentian Marian Youth Association of the
Province of the West.
NAME OF ACTIVITY: =
Vincent=
ian
Marian Youth Association
Saint V=
incent
de Paul
Feast D=
ay
Celebration
DATE OF ACTIVITY: =
<=
u>Saturday,
September 23, 2006 from 11 am – 5 pm at Carriage Manor House
TRANSPORTATION: &n=
bsp; ON
OWN
I have the following medical insurance that would
cover any hospital, medical and related costs and expenses in the event of
illness, sickness or accident of an emergency nature, as follows:
__________________________________________________=
______________________________
__________________________________________________=
______________________________
In the event I am injured, become ill and require
emergency medical attention, any resulting hospital, medical or related cos=
ts
and expenses will first be paid by the medical insurance or benefit plan of
mine or my spouse.
EMERGENCY CONTACT: ______________________________<=
span
style=3D'mso-tab-count:1'> PHONE: __________=
____
I am not aware of any medical condition which would
render it inappropriate for me to participate in any such activity.
I hereby give permission to the physician selected=
by the
Vincentian Marian Youth Association personnel then present to render medical
treatment deemed necessary and appropriate by the physician.
Execution of this document is not a waiver of any
rights against any responsible party in the event of an accident caused by a
third party, including an employee of the Vincentian Marian Youth Associati=
on
of the Province of the West.
I have discussed this waiver as well as appropriate
behavioral expectations with my young person or parent(s).
STUDENT SIGNATURE: ____________________________
Printed Name: &nbs=
p; _________________________________________
PARENT SIGNATURE:&=
nbsp; ________=
____________________ Date:
_____________
Printed Name: =
; _________________________________________