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Adult Release Form-OHIO MARCH FOR LIFE

- Jr High & The Well High School
  - High School Youth Events
    
    Ohio March for Life - Youth Participant Release Form
    Adult Release Form - Ohio March for Life
    
    National Eucharistic Congress
    Diocese of Columbus Safe Environment Manual
    The Well HS Youth Ministry Parent Waiver
    The Well Youth Group Sign-In
    The Well HS Youth Ministry Parent Waiver

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- DIOCESE OF COLUMBUS
  REGISTRATION/PERMISSION/RELEASE AND INDEMNIFICATION AGREEMENT
  
  PARISH NAME(S): Our Lady, Queen of Apostles
  PARISH CITY: Chillicothe, OH
  NAME OF ADULT LEADER: Andrea McLean [email protected] // 740-701-2654
  ACTIVITY: Ohio March for Life
  LOCATION: The Ohio Statehouse, 1 Capital Square, Columbus, OH 43215
  DATE: Friday, October 4th, 2024
  (Drop off and pick up at Bishop Flaget School 270 Parsons Ave., Chillicothe, OH 45601)
  9am All School Mass, 12pm March for Life, Return 2:20pm
  TRANSPORTATION: Bus
  Please pack a lunch!
- Adult Participant REQUIRED Please fill out this field.
  
  Registration 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthday REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Male Female Please fill out this field.
  
  T-shirt Size REQUIRED Please fill out this field.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
  
  Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
  
  Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
  
  Dietary Restrictions Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
  
  Any physical limitations? Please enter valid data.
  
  Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
  
  You should be aware of these special medical conditions of the Participant: Please enter valid data.
  
  B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
  
  Directions for medications:
  
  C. NON-PERSCRIPTION MEDICATION
  
  Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
  
  Registration 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthday REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Male Female Please fill out this field.
  
  T-shirt Size REQUIRED Please fill out this field.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
  
  Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
  
  Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
  
  Dietary Restrictions Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
  
  Any physical limitations? Please enter valid data.
  
  Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
  
  You should be aware of these special medical conditions of the Participant: Please enter valid data.
  
  B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
  
  Directions for medications:
  
  C. NON-PERSCRIPTION MEDICATION
  
  Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
  
  Registration 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthday REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Male Female Please fill out this field.
  
  T-shirt Size REQUIRED Please fill out this field.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
  
  Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
  
  Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
  
  Dietary Restrictions Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
  
  Any physical limitations? Please enter valid data.
  
  Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
  
  You should be aware of these special medical conditions of the Participant: Please enter valid data.
  
  B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
  
  Directions for medications:
  
  C. NON-PERSCRIPTION MEDICATION
  
  Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
  
  Registration 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthday REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Male Female Please fill out this field.
  
  T-shirt Size REQUIRED Please fill out this field.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
  
  Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
  
  Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
  
  Dietary Restrictions Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
  
  Any physical limitations? Please enter valid data.
  
  Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
  
  You should be aware of these special medical conditions of the Participant: Please enter valid data.
  
  B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
  
  Directions for medications:
  
  C. NON-PERSCRIPTION MEDICATION
  
  Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
- EMERGENCY MEDICAL CONTACT AND TREATMENT
- Emergency Contact
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relation to you? REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Medical Treatment
  
  In the event of an emergency, the undersigned hereby give(s) permission to transport the Participant to a hospital for emergency medical or surgical treatment. The undersigned wish(es) to be advised prior to any further treatment by the hospital or doctor.
  
  I Agree Please select this field.
- Medical Insurance Information
  
  Medical Insurance Provider REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Provider Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Member's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Permission and Release Forms
  
  RELEASE AND INDEMNIFICATION
  
  A. Release. The undersigned hereby state(s) that on behalf of the undersigned and the hiers, successors and assigns the undersigned hereby releases, holds harmless from any liability, and discharges from all direct or derivative claims, actions, causes of actions, medical expenses, costs, legal expenses, other expenses and all other damages at law or equity, known or unknown, direct or indirect, choate or chohate against the Diocese of Columbus, the Parish and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish, arising from the Participants participation in the Activity named section I. B., above. (he/she/they) (is/are) the (parent/parents/guardian) of the above named Participant and have full legal responsibility for the Participant. The undersigned hereby grant(s) permission for the Participant to participate in the Activity named in Section above.
  
  B. Indemnification. The undersigned shall indemnify and hold harmless the Diocese of Columbus, the Parish, and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish from any claim, liability, suit, judgment, loss, damage, expense, fee or cost (including court costs and attorney fees) arising directly or indirectly from the Participant’s participation in the Activity named in Section I.B., above, unless arising from the negligence of an indemnified party.
  
  CONSENT FOR RELEASE OF PERSONALLY IDENTIFIABLE INFORMATION
  
  The undersigned hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus and St. Peter and St. Mary Church for future promotional programs of the Diocese and Parish. If you have any questions or concerns, please contact Andrea McLean (Parish Point of Contact) at 740-701-2654
  
  Please choose an option below REQUIRED I consent to release of personally identifiable information I DO NOT consent to release of personally identifiable information Please fill out this field.
  
  CONSENT FOR RELEASE OF PERSONALLY IDENTIFIABLE INFORMATION
  
  The undersigned hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus and St. Peter and St. Mary Church for future promotional programs of the Diocese and Parish. If you have any questions or concerns, please contact Andrea McLean (Parish Point of Contact) at 740-701-2654
  Please click here if you consent to the release of personally identifiable information Please select this field.
- Code of Behavior
  
  The Participant shall comply with the following:
  
  A. Adults shall at all times conduct themselves in a lawful manner appropriate to the Activity. Adults shall act with respect for all other participants in the Activity. Adults shall act in accordance with the principles of the Roman Catholic Church.
  
  B. Student Activities: Adult participants shall at all times be present and shall chaperone students assigned by group leader. Adult participants will supervise and monitor movement of students throughout the activity. Adult participants will insure that no students enter areas specifically prohibited. Adult participants will insure that no students enter any rooms or areas that not appropriately chaperoned by two adults. Adult participants will use safe environment practices such as not meeting with with students in secluded areas; making sure enough adults are chaperoning all activities; observing other adults who are interacting with youth; and notifying OYYAM staff of any inappropriate activities throughout the duration of the activity. Adult participants will respect that the sessions are designed for the benefit of the students and will refrain from excessive questions or participation in the sessions. The possession or use of alcohol, tobacco, drugs, or weapons of any kind by students or adult participants is not permitted. Failure to abide by the Code of Behavior may result in a request for the adult to leave the premises.
- Safe Environment Compliance
  
  Date of Criminal Background Investigation Report REQUIRED Please fill out this field. Please enter a date.
  
  Date of Protecting God's Children Training REQUIRED Please fill out this field. Please enter a date.
  
  Location of Protecting God's Children Training REQUIRED Please fill out this field. Please enter valid data.
- Signature
  
  I HAVE READ AND UNDERSTAND AND AGREE TO ACCEPTS ALL CONTAINED IN THIS AGREEMENT.
  
  I HAVE READ AND UNDERSTAND THE ABOVE CODE OF BEHAVIOR AND COMMIT TO UPHOLD THIS CODE OF BEHAVIOR .
  
  I AFFIRM THAT THE SAFE ENVIRONMENT COMPLIANCE INFORMATION I HAVE PROVIDED IS COMPLETE AND TRUTHFUL.
  I Agree Please select this field.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Would you like to give a $10 donation towards the cost of the bus? REQUIRED Yes, I'm happy to bring a $10 donation the day of the event. Yes, I'd be happy to give online through Venmo or PayPal. No, but I am so grateful to participate in the event! Please fill out this field.
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Our Lady, queen of the apostles

The Catholic Community in Ross & Pike Counties

Adult Release Form-OHIO MARCH FOR LIFE