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  PERMISSION /WAIVER FOR 2022 LIFE TEEN LOCK-IN

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  • Participant's Information
  • First Name REQUIRED Please fill out this field. Please enter valid data.

    Last Name REQUIRED Please fill out this field. Please enter valid data.
  • Male/Female REQUIRED (Select One) Female Male Please fill out this field.
  • Grade REQUIRED (Select One) Freshman Sophomore Junior Senior Please fill out this field.
  • Allergies, Physical Restrictions, other Special Medical Conditions
  • Medications & Dosage
  • Insurance Company and ID Numbers Please enter valid data.
  • Emergency Contact Name & Phone Number if parent/guardian is not reachable. REQUIRED Please fill out this field. Please enter valid data.
  • Parent/Guardian's Name REQUIRED Please fill out this field. Please enter valid data.
  • Parent/Guardian's Phone Number REQUIRED Please fill out this field. Please enter valid data.
  • Parent/Guardian's Email REQUIRED Please fill out this field. Please enter valid data.
  • I grant permission for my child to participate in this overnigth parish event at St. Joseph Catholic Church, Lebanon, Indiana. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Joseph Catholic Church, and the Diocese of Lafayette-in-Indiana. 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. Joseph Catholic Church, Lebanon, Indiana and the Diocese of Lafayette-in-Indiana, 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. I agree to compensate the Diocese of Lafayette-in-Indiana, its employees and agents and chaperones, or representative associated with the event, for reasonable attorney’s fees and expenses which may incur any action brought against them as a result of such injury or damage unless such claim arises from the negligence of the parish/diocese.
    
    In the event of an emergency, I hereby give my permission 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 the listed Emergency Contact included above.
    
    I grant to St. Joseph Church, Lebanon, Indiana and the Diocese of Lafayette-in-Indiana the right, privilege and license to use the picture or likeness of my child in any photograph, movie, video production or any other forms of media publication and to use the verbal or written statements or declarations of my child for the purpose of publicizing, fostering and promoting the diocese and its programs, or for any other purpose in furtherance of the mission of the Diocese of Lafayette-in-Indiana.
  • I Agree Please select this field.
  • Parent/Guardian's Signature REQUIRED Please fill out this field. Please enter valid data.
  • Date REQUIRED Please fill out this field. Please enter a date.

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