ARCHDIOCESE OF
PERMISSION, RELEASE
AND MEDICAL POWER OF ATTORNEY (rev.
7-2005)
1. I, the lawful parent or guardian of
________________________________________(the “child”), give permission for my
child to participate in the activity described on the reverse and release from
all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”),
both individually and as trustee for the Archdiocese of Cincinnati and all
parishes within the Archdiocese, and their officers, agents, representatives,
volunteers, and employees from any and all liability, claims, judgements, cost or expenses, including attorney fees,
arising out of any injury or illness incurred by my child while participating
in or traveling to or from the activity.
2. I agree to instruct my child to cooperate with the
Archbishop or his agents in charge of the activity.
3a. I appoint the Archbishop or his agents who are
acting as leaders of the activity as my attorney in fact to act for me in my
name and my behalf, in any way that I would act if I were personally present,
with respect to the following matters if any injury, illness or medical
emergency occurs during the activity or related travel:
(i)
To give any and all consents and authorizations to any physicians, dentist,
hospital or other persons or institutions pertaining to any emergency
medications, medical or dental treatments, diagnostic or surgical procedures or
any other emergency actions as our attorney shall deem necessary or appropriate
for the best interest of the child.
(ii) I understand that the
agents of the Archbishop will make a reasonable attempt to contact me as soon
as possible in the event of a medical emergency involving my child.
3b. This power of attorney
shall lapse automatically upon completion of the activity and related travel.
4. I agree that the Archbishop or his agents may use
my child’s portrait or photograph for promotional purposes, website and office
functions.
I have carefully read this statement, and my signature
acknowledges that I fully understand the content and meaning.
Signature of Parent or
Guardian_____________________________________________ Date /
/
Address________________________________________
City____________________________ Zip ________
Place of Employment_________________________________________________________________________
Address________________________________________ City
___________________________ Zip_________
Phone: (w) _____________(h)______________
Emergency Contact ___________________________ Phone:
(w)_________________ (h)___________________
************************************************************************
Medical Information — Completed by Parent or Guardian
— Please Print
Child’s Name
_________________________________________________ Birth date ______/ _____/
______
Child’s Soc. Sec. # *_______________________________
Allergies
___________________________________________________________________________________
Medications
________________________________________________________________________________
Chronic Conditions (e.g. epilepsy, diabetes)
_______________________________________________________
Medical Insurance Co.
_______________________________________ Policy No. _______________________
Member’s Name ____________________________________
Phone: (h) ______________ (w) _____________
Member’s Birth date ______/ _____/ ______ Member’s
Soc. Sec. # *__________________________________
Family Doctor ______________________________________
Phone __________________________________
* Social Security number is optional. Please note that
some hospitals WILL NOT treat without it.
ACTIVITY
INFORMATION
Completed
by Church Agency
Deadline:
Church
Agency:
Starting
Date:
Registration
Fee: $40 per child
Usual
Location: Pilliod Hall/Rosary
Hall Usual day and time: Sunday, bi-monthly,
Routine
Activities: Catechesis, Prayer
Group
Leader: Liza Peters Telephone #: 836-7535