Adult Participation Form & Release

Participant's Name*

First Last

Birth Date*

Sex*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Business Phone*

I understand that I assume the risks inherent in the field trip or other activity outside of my child’s school, and with full knowledge of the risks, I, and my heirs, successors and assigns, release and agree to hold harmless and defend _Notre Dame High School_Inc., The Diocese of Allentown, Most Reverend Alfred A. Schlert, D.D., J.C.L. the Roman Catholic Diocese of Allentown Charitable Trust, and all of their respective members, trustees, directors, officers, employees and representatives, including chaperones, volunteers or any other representatives associated with that activity (all of whom are separately and collectively referred to as the Diocese) from claims from or related to my participation, or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese for reasonable attorney’s fees and expenses incurred by the Diocese in any action brought against the Diocese as a result of such injury or damage, unless such claim results from the negligence of the Diocese.

Agree
Disagree

Description of Trip

Type of Event*

Destination of Event*

Estimated Time of Departure and Return*

Travel Information*

(airline, flight numbers, bus or train information)

Medical Matters

I hereby warrant that to the best of my knowledge, I am in good health, and I assume responsibility for my health.

In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical or surgical treatment. In the event of an emergency, contact:

Name*

First Last

Relationship*

Phone*

Family Doctor*

First Last

Phone*

Health Plan Carrier*

Policy #*

I.D. #*

The parish/school should be aware of the following medical conditions. (The parish/school will take reasonable care to see that the following information will be held in confidence.)

Allergic Reactions:*

(medications, foods, plants, insect, etc.)

Physical Limitations or Other Special Medical Conditions:*

I have read carefully this entire Adult Participation Form and Release and agree to its terms and intend to be bound hereby.

Participant’s Signature*

Today's Date*

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Description of Trip

Medical Matters

Athletics