Event & Location: EDGE Middle School Youth Group, Schiavone Parish Center

Date & Time: Friday, 5:30 - 7:15 pm

Transportation: NOT PROVIDED

The above child is eligible to participate in above parish-sponsored event requiring transportation to a location away from the parish grounds. This activity will take place under the guidance and supervision of employees/volunteers from the above parish.

If you would like your child to participate in this event, please read, complete, sign, and return this form which includes your consent, as well as full release of liability. As parent or legal guardian, you remain fully responsible for any acts of the named child during this activity.

The undersigned parent, guardian or legal representative hereby consents to the participation of the above-noted child in the event described and further consents to the conditions stated above on participating in this event, including the method of transportation. It is understood that this event will take place away from the parish grounds and that the child will be under the supervision of a designated parish employee(s)/volunteers on the stated dates.

For and in consideration of the child being allowed to participate in this event, and other valuable consideration, the undersigned parent, guardian or legal representative, on behalf of the child and the child’s parents, personal representatives, assigns, heirs, and next of kin, does hereby release and hold harmless the Diocese of St. Augustine, Bishop Erik T. Pohlmeier, as Bishop of the Diocese of St. Augustine, a corporation sole, Bishop Erik T. Pohlmeier, individually, the above-noted parish, and employees and agents of said parties engaged in this particular event, their personal representatives or assigns, from any loss or damage on account of any injury to the person or the personal property, of the child, or death, caused by negligence or otherwise, while the child is engaged in the above-stated event or in transportation to and from said event. The undersigned expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and that if any portion of this Agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

(Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to Diocese of St. Augustine’s employees, volunteers, or representatives to seek medical treatment for my child above named.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and to order injection and / or anesthesia and / or surgery for my child above named.

In the event of an emergency, if you are unable to reach me at the above number, contact:

If a certain field does not apply to your child, then please just enter "NA" as all fields require some form of input. Thank you!