I, the above mentioned parent/guardian, hereby grant permission and consent for the child to attend this High School Youth Ministry event, which I understand to be an overnight supervised youth program.
I understand that the event is being held at St. Leonard Youth Retreat Center, 4076 Case Rd in Avon, Ohio. I understand that the event begins on Saturday, April 6, 2019 at 9:30am and ends on Sunday, April 7, 2019 at 3pm (times approximate). I undertake the responsibility to assure that my child will receive transportation to and from the event at the aforementioned times. I understand that St. Thomas More Church and the St. Thomas More Youth Ministry Staff are not providing transportation to and from the aforementioned event. I assume responsibility for the aforesaid transportation.
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.