I hereby request permission for the above named child to attend the Time Out Retreat Game Night with the St. Thomas More Youth Ministry on Sunday, December 9, 2018 from 6pm until 8pm and I consent to the child’s participation in such a field trip. I understand that no transportation will be provided and I agree to pick-up and drop-off my child at the requested times.
In consideration of the child being allowed to participate in this event on behalf of this child, my spouse, myself and my child’s estate, I hereby assume all risks in connection with the aforesaid event and further release the Bishop of the Roman Catholic Diocese of Cleveland, St. Thomas More Roman Catholic Church of Brooklyn, Ohio, the St. Thomas More Youth Ministry Program, and the advisory board members, employees, volunteers, adult chaperones, clergy and advisors of the foregoing from any and all claims, judgments and liability for any injury whether personal or property, that the child, his/her estate, my spouse, now has, ever had, or may have due to participation in this event, including all risks connected therewith, whether foreseen or unforeseen.
I authorize Mr. Jeff Stutzman, or any other adult chaperone or adult youth group advisor in whose care the child has been entrusted, to consent to any X-Ray, examination, anesthesia, medical or surgical diagnosis or treatment and hospital care to be rendered to the child under general or specific supervision of any physician or surgeon licensed to practice in the State of Ohio, and consent to any X-Ray, examination, anesthesia, dental or surgical diagnosis or treatment, and hospital care to be rendered to the child by any dentist licensed to practice in the State of Ohio.
I give the authorization on the condition that I may not be reached by the telephone numbers provided or if consent by telephone is not valid by state law.
I hereby give consent to photograph or videotape my child and without limitation to use such photography or videotapes and or stories connected with any work of the St. Thomas More High School Youth Ministry without consideration of any kind, and I do hereby release the St. Thomas More Youth Ministry from any claims whatsoever which may arise in said regard.
I fully understand what is involved in this trip and I understand that I have the opportunity to call my child’s youth minister at St. Thomas More Church at 749-0414 with any questions I may have.
I also understand that if my child should violate any of the rules set forth for this event that I may be notified regardless of time to pick them up from the event.