Child's Name* ARCHDIOCESE OF CINCINNATI PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY 1. I, the lawful parent or guardian of my child (the “child"), give permission for my child to participate in the activity described on the reverse and release from all liability and indemnify the Archbishop of Cincinnati ("the Archbishop"), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgements, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity. 2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity. 3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel: (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child. (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child. 3b. This power of attorney shall lapse automatically upon completion of the activity and related travel. 4. I agree that the Archbishop or his agents may use my child's portrait or photograph for promotional purposes, website, and office functions. I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning. Signature of Parent/Guardian* Reset signature Signature locked. Reset to sign again Name of Parent/Guardian* Date* MM slash DD slash YYYY Address Street Address City Zip Home PhoneCell Phone*Email* Place of Employment Wk. Phone*Address Street Address City Zip Emergency Contact* Phone (w)Phone (h)Phone (cell)*ACTIVITY INFORMATIONCompleted by Church Agency - Please Print (As a convenience to parent(s) or guardian(s), a duplicate copy of this information may be attached so as to be retained by them; also any additional information may be attached to further inform them of specific scheduling details, additional activity information, etc.) Program Church Agency: Activity: Location Emergency No.Cost Starting Date and Time Ending Date and Time Meeting Place Type of Transportation (if any) Activities Involved: Other Information Medical Information / ORAL MEDICATION ADMINISTRATION RELEASE FORMCompleted by Parent or GuardianChild's Name* First M.I. Last Birth Date* MM slash DD slash YYYY Child’s Social Security # * List any allergies:*List any Medications:*List any Chronic Conditions (e.g. epilepsy, diabetes):*Medical Insurance Co.* Policy No.* Member’s Name* Phone (h)*Phone (w)*Member’s Birth Date* MM slash DD slash YYYY Member’s Social Security # Family Doctor* Phone** Social Security number is optional; however, please note that some hospitals WILL NOT treat without it. * If your child is bringing medication(s), bring ONLY THE AMOUNT of medication needed for the event. List the type and specific instructions for administering it: If the Need Arises, Please Give My Child: Tylenol Ibuprofen Aspirin Nothing TO: Director of Religious EducationRE: StudentWe/I the undersigned, the parent/foster parent/guardian of above student request that ORAL* medication be administered to our child in accordance with the instructions of our physician. We understand that the administration of said medication is to be done under the supervision of a member of the Parish Staff. We/I further understand that the St. Peter personnel are not legally obligated to administer oral medication to any child. Therefore, I/we agree to hold the parish and its employees free from any and all responsibility for the results of such medication or the manner in which it is administered and to indemnify each of them against loss by reason of civil judgement arising out of these arrangements which may be rendered against them. *Oral medication, for release, refers to medication in pill form only. Liquid medication that must be measured cannot be administered. Also, the Parish staff will not assume the responsibility for administering in injections, applying ointments, or changing dressings. **Both parents must sign this release if they are living with or have custody of the child. If parents are separated and both still retain legal custody, both parents must sign. If children are in a foster home and placement is by an agency that holds custody, the agency must sign. ** signature of father Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY ** signature of mother Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Address Street Address City Zip Home PhoneCell PhoneWork Phone
