2024 St. Henry CYO Participation Form

Participation Form for Middle School (5-6th grade) JR (7th and 8th grade) and SR CYO (high school)

This form allows your child to attend all CYO functions on and off campus- Please be sure to spell your teen's name correctly

Student Information

Name (Student)

Date of Birth

School Teen Attends:

Graduation Year from High School:

2025 2026 2027 2028 2029 2030 2031 2032

Gender

Female Male

Parent Information (Emergency Contact)

Parent Email

This address will receive a confirmation email

Parent Phone (Emergency Contact)

Address

Parent Name(s) Please include 2 if divorced or separated

Additional Emergency Contact (can be a friend or someone that is allowed to pick up your child in the event we cannot reach you)

Emergency Contact Relationship to Child

Emergency Contact Number #2 (first listed above)

Medical and Insurance Considerations

Please list any medicine, environmental, and/or food allergies as well as dietary restrictions in this box:

Special Health or Medical Considerations: (please list anything that a minister would need to know about your child including physical and intellectual disabilities or diagnosis) IE autism or OCD. This helps us when providing a comfortable environment for students and pairing with leaders and groups

Health Insurance Company

Group Policy Number

By typing your name you are electronically signing the statement.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Henry Catholic Church, its officers, directors, employees and agents, and the Diocese of Nashville, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Diocese of Nashville, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese. By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By typing your name, you consent to be legally bound by this Agreement's terms and conditions.

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. I hereby grant permission for non-prescription medication (such as acetaminophen or ibuprofen, throat lozenges, band-aids, antibiotic ointment, hot/cold packs, etc...) to be given to my child, if deemed appropriate.I grant permission to the chaperones to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached I hereby give my consent to such treatment as deemed necessary (including surgery, x-ray examinations and anesthesia to be rendered to said minor by a licensed physician, nurse). By typing my name here, I signify that I am the parent of the child/children listed above and I agree to the release/waiver detailed above.

I understand that if private vehicles are used to transport minors, St. Henry Church and the Diocese of Nashville have no insurance coverage for that vehicle. By typing my name here, I signify that I am the parent of the child/children listed above and I agree to the release/waiver detailed above.

Futher, I release the Diocese of Nashville/St. Henry Church, staff, chaperones and drivers from any claims connected with participation of said minor in CYO events. By typing my name here, I signify that I am the parent of the child/children listed above and I agree to the release/waiver detailed above.

Image Release for St Henry Church: During the year, the Parish Staff may take photos or videos of student activities and events. We occasionally would like to use the photos on our website, social medial, share with students or display through publications and presentations. Please type your name below to consent the use by St. Henry Church and the Diocese of Nashville of your child's photo (in all forms) and manner for educational, instructional or promotional purposes. I hereby waive any right to inspect or approve the finished version of any copy. I also understand that no royalty, fee or other compensation shall become payable to me because of such use.

Additional questions or comments:

2024 St. Henry CYO Participation Form

Description

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