Church of The Little Flower

Berkeley Heights, New Jersey

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Participantʼs Name: _____________________________________ Birth Date: ___________________

Parent/Guardianʼs Name: _____________________________________________________________

Home Address: ___________________________ E-mail Address: _____________________________

Home Phone: ______________________________ Cell Phone: ______________________________

I, (name of parent or guardian) ____________________________________, grant permission

for my child (name of child) __________________________________, to participate in the Life Teen Annual
Retreat from May 20, 2011 at 5:00 pm to May 22, 2011 at 6:30 pm at the Sacred Heart Spirituality Center in
Newton, NJ (the “event”). I understand that my child may be driven to and from the Sacred Heart Spiritual
Center from Church of The Little Flower in accordance with the guidelines outlined by the Roman Catholic
Archdiocese of Newark on transportation of minors.

For value received, I agree on behalf of myself, my childʼs other parent/guardian if

known or living (name of parent) __________________________________ my child named herein, or our

heirs, successors, and assigns, to hold harmless and defend Church of The Little Flower, its officers, directors,
agents, representatives, volunteers, employees, or chaperones associated with the “event”, arising from or in
connection therewith, and I agree to compensate Church of the Little Flower, its officers, directors, agents,
representatives, volunteers, employees, and chaperones associated with the “event” for reasonable attorneyʼs
fees and expenses arising in connection therewith.
Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all
responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only
those in accordance with your wishes.
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to Church of the Little
Flower, its officers, directors, agents, representatives, volunteers, chaperones, or representatives associated
with the event, to transport my child to a hospital for emergency medical or surgical treatment. I wish to be
advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable
to reach me at the above numbers, contact:

Name and Relationship : ________________________________________________________

" Telephone: __________________________________

Family Doctor : _______________________________________________________________

" Telephone: __________________________________

Family Health Plan Carrier : _____________________________________________________

" Policy Number: __________________________________

(1) Signature: __________________________________________ Date: ________________________

PLEASE TURN OVER AND COMPLETE THE BACK OF THIS FORM

Other Medical Treatment: In the event it comes to the attention of Church of The Little Flower, its officers,
directors, agents, representatives, volunteers, employees, chaperones or representatives associated with the
“event”, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want
to be called REGARDLESS of the Time, etc.

(2) Signature: __________________________________________ Date: ________________________

Medications: My child is taking medication at present. My child will bring all such medications necessary, and
such medications will be well-labeled. Names of medications and concise directions for seeing that the child
takes such medications, including dosage and frequency of dosage are as follows:

___________________________________________________________________________________

(3) Signature: __________________________________________ Date: ________________________

No medication of any type whether prescription or non-prescription may be administered to my child unless the
situation is life-threatening and emergency treatment is required.

(4) Signature: __________________________________________ Date: ________________________

I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be
given to my child, if deemed advisable.

(5) Signature: __________________________________________ Date: ________________________

Specific Medical Information: Church of The Little Flower will take reasonable care to see that the
following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc) ____________________________________

Immunizations (date of last tetanus/diphtheria) _____________________________________________

Medications child currently takes ________________________________________________________

Does child have a medically prescribed diet? ______________________________________________

Any physical limitations? ______________________________________________________________

Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking,

bedwetting, fainting? _____________________

Has child been recently exposed to contagious disease or condition, such as mumps, measles, chicken

pox, etc? If so, what condition? _________________________________________________________

You should also be aware of these special medication conditions of my child:

____________________________________________________________________________________

I fully understand the consequences of the foregoing statements and sign this PARENTAL/GUARDIAN
CONSENT FORM AND LIABILITY WAIVER knowingly, freely, and willingly.
YOUR SIGNATURE MUST APPEAR BELOW OR YOUR CHILD WILL NOT BE
PERMITTED TO ATTEND THE “EVENT”

(6) Signature: __________________________________________ Date: ________________________