Time Out 29 Permission Slip & Medical Form

  • Overnight Permission Slip and Medical Release
    Event: Timeout 29-Overnight Retreat
    Begins: Saturday, April 6, 2019 at 9:30am
    Ends: Sunday, April 7, 2019 at 3:00pm
  • 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.

  • The following including any allergies the child may have, any medications, the child may be taking and other facts which a physician or dentist should be alerted to:
  • 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 on both page one and page two of the foregoing form 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.

  • If paying by check, please make checks payable to St. Thomas More High School Group.

  • Price: $30.00