PERMISSION TO PARTICIPATE IN ACTIVITIES MISSION NETWORK ACTIVITIES USA, INC.
Please CLICK HERE to download and print an Parental Consent and Emergency Medical Information and Release for each participant.
- NATURE AND DURATION OF ACTIVITIES: Activities include but are not limited to: Daily Mass, talks, confession, adoration, spiritual mentoring, laser tag, work projects and other outdoor activities, sports, hiking, campfires.
Event: Boys Weekend Camp, Feb 10-12, 2017
- ACTIVITY SUPERVISOR(S): Fr Matthew Schmitz LC, Adrian Garcia, David Roy, Fr Michael Sullivan LC, Fr Daren Weisbrod LC, Fr Michael Vanderbeek LC.
- TRANSPORTATION: Not Applicable. Participants are responsible for securing their own transportation to and from activities, as the company does not provide transportation.
- MENTORING: Participants may be offered mentoring, which is intended to help young people personalize the principles of Christian living that they receive at home and in club or retreat activities. Mentoring involves a private conversation with an adult conducted in plain view of others. When dealing with adolescents, confidentiality will be maintained to foster openness of dialogue, but situations involving sexual abuse of a minor or threats to life or physical health will be reported to the appropriate authority and to the parents (except in those cases where the parent may be the alleged abuser).
- REQUIREMENTS: The child named above is in good health and has no physical or medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify allergies and medical problems in section 9 below.
- CONSENT: I/We hereby consent to the above-named child's participation in the activities described above including mentoring, and specifically request that he be allowed to participate in those activities. I/We warrant that I/We have full authority to legally consent to his participation in the activities described on this form, and all provisions contained herein.
- AUTHORIZATION. I/We hereby authorize Mission Network Activities USA, Inc. to use the image and likeness of my/our child in photograph or video form whether taken by or commissioned by Mission Network Activities USA, Inc. in its promotional materials and for its promotional purposes associated with its nonprofit activities. This authorization shall extend to use of my/our child’s image and likeness on the website of Mission Network Activities USA, Inc., or its successor in operation or affiliated organization(s) upon written consent of Mission Network Activities USA, Inc. I/We understand that this authorization shall survive the end of my/our child’s participation in the activities referenced on this form.
- INSURANCE: I/We understand that Mission Network Activities USA, Inc. does not carry any health insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my/our own insurance carrier; or (b) that I/We am/are personally financially responsible for any and all medical costs incurred as a result of the child's injury.
- EMERGENCIES: If the above-named child requires any emergency medical procedures or treatments during the activities, I/We consent to the activity supervisor(s) taking, arranging for or consenting to such procedures or treatments in the discretion of the activity supervisor(s). For purposes of such procedures and treatments, my/our child's blood type allergies or other medical problems (if any) are listed above.
- EMERGENCY CONTACTS: EMERGENCY CONTACTS: If, in the event of a medical or other emergency, I/We am/are unable to be reached by telephone at the numbers listed below, I/We authorize the activity supervisor(s) to attempt to contact me/us through the alternative emergency contacts listed below.
RELEASE AND INDEMNIFICATION:
I/We release and waive, and further agree to indemnify, hold harmless or reimburse Mission Network Activities USA, Inc. and Consolidated Catholic Administrative Services, Inc., the individual members, agents, directors, officers, employees, volunteers and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses (including attorneys’ fees incurred by Mission Network Activities USA, Inc. and Consolidated Catholic Administrative Services, Inc., or any of its individual employees, agents, volunteers, etc. in enforcing this indemnity provision) without limitation in time or amount, damages or injuries arising out of, during, or in connection with my/our child's participation in the activities, the travel to and there from, and the rendering of emergency medical procedures or treatment, if any.
