Parish Permission Slip Release form
$

Participants Information

Contact Information

School Information

Emergency Contact

Health Information

Steubenville West Waiver

I,
am either an emancipated adult or the parent or guardian of a minor child who will be participating in the Life Teen
Steubenville West. I am fully aware that my own/my child’s participation in Steubenville West is totally voluntary. In consideration of Life Teen’s agreement to permit me/my child to participate in Steubenville West, the receipt and sufficiency in which consideration is hereby acknowledged, I agree as follows:
I, individually, and on behalf of my minor child, if applicable, and our respective heirs, successors,
assigns and personal representatives, hereby:
1. Release, acquit and forever discharge Life Teen, Steubenville West, Franciscan University of Steubenville, and the site organization(s) and their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability whatsoever for any and all damages, losses or injuries to persons or property or both which arise out of, during or in connection with my/my child’s participation in Steubenville West which may be sustained or suffered by me/my child or any person in connection with my/my child’s association with, or participation in, activities at, sponsored by, or arising out of my/his/her travel to or from Steubenville West;
2. Agree to indemnify, defend and hold harmless Life Teen, Steubenville West, Franciscan University of Steubenville, and the site organization(s) and their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability, loss or damage they incur or sustain as a result of any claims, demands, actions, causes of action judgments, costs or expenses, including attorneys fees, which result from arise out of relate to my/my child’s participation in Steubenville West including my/his/her travel to or from Steubenville West.

I hereby acknowledge and accept that:
1. There are certain risks arising from various activities, including but not limited to bodily injury, that could result from my/my child’s participation in Steubenville West. I have knowingly and voluntarily decided to assume the risks of these inherent dangers in consideration of Life Teen’s permission to allow me/my minor child to participate in Steubenville West;
2. My and, if applicable, my child’s personal property is at my risk entirely;
3. Life Teen reserves the right to decline to accept or retain me/my child in Steubenville West at any time should my/his/her actions or general behavior impede the operation of Steubenville West or the rights or welfare of any person. I understand that I/my child may be required to leave Steubenville Westin the sole discretion of Life Teen’s agents and representatives. In such an event, no refund will be made for any unused portion of Steubenville West. I understand that Life Teen, in its sole discretion, reserves the right to cancel Steubenville West or any aspect thereof prior to commencement.

I represent and warrant that I am/my child is covered throughout Steubenville West by a policy of comprehensive health and accident insurance which provides coverage for injuries which I/he/she may sustain as part of my/his/her participation in Steubenville West or that we accept full responsibility for any and all expenses that are incurred due to injuries which I/he/she may sustain as part of my/his/her participation in Steubenville West. I agree to complete the HEALTH
INFORMATION above to the best of my ability and, by its completion, I hereby release and discharge Life Teen, Steubenville West, Franciscan University of Steubenville, and the site organization(s) of all responsibility and liability for any injuries, illnesses, medical bills, charges or similar expense/he/she may incur while participating in Steubenville West. By completing the form, I hereby authorize Life Teen to obtain any necessary medical treatment to myself/ my child, consent to any necessary examination, treatment, or care under the supervision and/or advice of any properly licensed medical professional and explicitly authorize Life Teen to release medical information about me/my child to any person or entity to whom Life Teen refers me/my child for medical treatment.

I agree that this Agreement is to be construed pursuant to the laws of the State of Arizona and is intended to be as broad and inclusive as permitted by law, and if any portion hereof is held invalid, it is agreed that the balance hereof shall continue in full legal force and effect. In addition, I agree that any legal action arising out of or in relation to this Agreement must be brought in a Maricopa County, Arizona court.

I hereby grant to Life Teen , Steubenville West , Franciscan University of Steubenville, and the site organization(s) my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child’s name, voice, image, and/or likeness that arises from his/her participation in Steubenville West, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at Life Teen’s sole discretion.

In signing this Agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights as well as, if applicable, those of my child, that it is a binding Agreement, and that I have signed it knowingly and voluntarily.

Archdiocese of Santa Fe Permission Slip

The undersigned as parent or legal guardian of the above teen does hereby gives permission for the above named individual to attend the described activity. As a condition of attending the described activity, I do hereby release the Roman Catholic Archdiocese of Santa Fe and all its affiliated parishes, schools, and organizations; as well as their officers, agents and employees; from any and all claims, demands, actions, or causes of action due to death, injury, or illness, in any way arising from the above described activity including, but not limited to transportation, to and from the event.

I further agree that the financial responsibility for securing care, in case of injury resulting from participation in the program, is a matter between the participant and his/her health provider, and that The Archdiocese of Santa Fe cannot pay health care providers for treatment of any injuries. It is further agreed that the participant will assume all legal responsibility for their personal safety and actions while participating in the program and while traveling to and from the program activities.

I hereby authorize the Supervisor of the activity or hi/her designee to act in my behalf to authorize such medical attention, surgery, or other health care services, as may be recommended in an emergency situation while participation in the activity. If the above named physician cannot be reached, I hereby authorize any licensed physician or medical center to treat my child.

I am either an emancipated adult or the parent or guardian of a minor child who will be participating in the St. Thomas Aquinas. (“STA”) Event. I am fully aware that my own/my child’s participation in The Event is totally voluntary. In consideration of STA’s agreement to permit me/my child to participate in The Event, the receipt and sufficiency in which consideration is hereby acknowledged, I agree as follows:

I, individually, and on behalf of my minor child, if applicable, and our respective heirs, successors, assigns, and personal representatives, hereby:
1. Release, acquit and forever discharge STA, Roman Catholic Archdiocese of Santa Fe and all its affiliated parishes, schools, and organizations; as well as their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability whatsoever for any and all damages, losses or injuries to persons or property or both which arise out of, during or in connection with my/my child’s participation in The Event which may be sustained or suffered by me/my child or any person in connection with my/my child’s association with, or participation in, activities at, sponsored by, or arising out of my/his/her travel to or from The Event;
2. Agree to indemnify, defend and hold harmless STA Roman Catholic Archdiocese of Santa Fe and all its affiliated parishes, schools, and organizations; as well as their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability, loss or damage they incur or sustain as a result of any claims, demands, actions, causes of action judgments, costs or expenses, including attorneys fees, which result from arise out of relate to my/my child’s participation in The Event including my/his/her travel to or from The Event.

I hereby acknowledge and accept that:
1. There are certain risks arising from various activities, including but not limited to bodily injury, that could result from my/my child’s participation in The Event. I have knowingly and voluntarily decided to assume the risks of these inherent dangers in consideration of STA’s permission to allow me/my minor child to participate in The Event;
2. My and, if applicable, my child’s personal property is at my risk entirely;
3. STA reserves the right to decline, to accept, or retain me/my child in The Event at any time should my/his/her actions or general behavior impede the operation of The Event or the rights or welfare of any person. I understand that I/my child may be required to leave The Event in the sole discretion of STA’s agents and representatives. In such an event, no refund will be made for any unused portion of The Event. I understand that STA, in its sole discretion, reserves the right to cancel The Event or any aspect thereof prior to commencement.

I represent and warrant that I am/my child is covered throughout The Event by a policy of comprehensive health and accident insurance which provides coverage for injuries which I/he/she may sustain as part of my/his/her participation in The Event. I agree to complete the HEALTH INFORMATION section to the best of my ability and, by its completion, I hereby release and discharge STA,Roman Catholic Archdiocese of Santa Fe and all its affiliated parishes, schools, and organizations; of all responsibility and liability for any injuries, illnesses, medical bills, charges or similar expense I/he/she may incur while participating in The Event. By completing the form, I hereby authorize STA to obtain any necessary medical treatment to myself/my child, consent to any necessary examination, treatment, or care under the supervision and/or advice of any properly licensed medical professional and explicitly authorize STA to release medical information about me/my child to any person or entity to whom STA refers me/my child for medical treatment.

I agree that this agreement is to be construed pursuant to the laws of the State of New Mexico and is intended to be as broad and inclusive as permitted by law, and if any portion hereof is held invalid, it is agreed that the balance hereof shall continue in full legal force and effect. In addition, I agree that any legal action arising out of or in relation to this agreement must be brought in a Sandoval County, New Mexico court.

I hereby grant to STA my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child’s name, voice, image, and/or likeness that arises from my/his/her participation in The Event, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at STA’s sole discretion.

In signing this agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights as well as, if applicable, those of my child, that it is a binding agreement, and that I have signed it knowingly and voluntarily.