Name and phone number of an adult to reach in case of emergency in the event that you cannot be reached at the numbers above.

I understand that the Catholic Diocese of Jefferson City and Totus Tuus assume no responsibility for accidents which may occur in association with diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participant as deemed necessary.

In the event it comes to the attention of the Diocesan and/or parish chaperones that my child complains of illness, I grant permission for non-prescription medication (such as Tylenol, lozenges, etc.) to be given to Participant.

I understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Jefferson City and Totus Tuus and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Catholic Diocese and Totus Tuus, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event.

I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant’s expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Jefferson City or its chaperones/representatives.

I hereby authorize the Catholic Diocese of Jefferson City and Totus Tuus and its agents to utilize photographic and/or video images of me or my child by the Catholic Diocese of Jefferson City. In giving my consent, I hereby indemnify and hold harmless the Catholic Diocese of Jefferson City and Totus Tuus and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used.