Release of Liability/Medical 2023-2024
Date of Activity: July 2023 - May 2024 Type of Activity: Any/all activities hosted by
St. Joseph Religious Education
Student Information / Información de Estudiante
Family Information / Información de familia
Padre / Guardián Primer Nombre
Apellido
Madre / Guardián Primer Nombre
Apellido
A receipt will be e-mailed to this address.
Emergency Contact
Release of Liability/Medical 2020-2021
(I)/We, Parent(s)/Legal Guardian(s) of the child listed above wish to register him/her and grant permission for him/her to participate in the above stated activities sponsored by St. Joseph Catholic Church and its Religious Education/Youth Ministry/Confirmation Programs.
In view of this registration to participate in the above stated church sponsored activity, (I)/We agree to release St Joseph Catholic Church and its ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatever which may be incurred by the undersigned and the child (children) participant that occur while said child (children) is/are participating in the above named activity, including transportation to and from such activity or trip.
In connection with the above stated church activity, (I)/We authorize the representative of St Joseph Catholic Church and its ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective for up to one year from the date of completion of this form, unless sooner revoked in writing delivered to said agent(s). In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I/we hereby release, defend and hold harmless St Joseph Catholic Church and the Roman Catholic Diocese of Dallas (Diocese), their officers, directors, agents, employees, volunteers, ministry leaders, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
Do you give permission for your child to receive from an appropriate church representative, over the counter medication for fever, head or muscle aches, and/or to be administered/supervised in the taking of allergy or other prescribed medication?
On occasion, during youth/confirmation, videotape, audio tape, slides, and photographs are taken of children and youth during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotions advertisements and other printed media. As the State of Texas does not prevent videotaping or the photographing of children/youth (with the exception of Senate Bill 1, Section 26.009 which deals specifically with school districts) it does encourage parental consent. Additionally, current videotapes and photographs assist law enforcement agencies dealing with the Missing Children’s Program. I/We hereby consent to the use of such materials in which my child may appear. I release the staff and volunteers of St Joseph Catholic Church and the Roman Catholic Diocese of Dallas from any liability connected with the use of my child’s picture or voice recording as part of any of the above or similar activities
I/We have read or it has been explained to me, the Social Media and Evangelization policy document and I give my permission for my child (14 and older) to participate on the youth ministry Facebook and Twitter communities/pages and receive SMS text messages from the coordinators of Youth Ministry and/or Director of Religious Education for the purpose of communicating relevant information such as an upcoming event or items of a religious nature.
THIS ONLY APPLIES IF YOUR CHILD IS 14 YEARS OR OLDER

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