Second Student's Information / Informacion del otro estudiante
RELEASE FORMS / FORMULARIOS DE PERMISO
As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set
forth by the Diocese and the Parish.
Como participante, me comprometo a seguir todos los procedimientos, precauciones de seguridad y normas y reglamentos establecidos
establecidas por la Diócesis y la Parroquia.
PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE
I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.
LIBERACIÓN DE FOTOS, PRENSA, AUDIO Y MEDIOS DE COMUNICACIÓN ELECTRÓNICOS
Autorizo a la Diócesis Católica de Arlington, sus parroquias, sus escuelas y/o al Arlington Catholic Herald a usar y publicar la fotografía, el video y/o la grabación de audio de mi hijo/a junto con su nombre que lo identifique para fines educativos, noticiosos, de ilustración y/o de marketing.
ALLERGIES (if any) / ALERGIAS (si las hay)
Please list any prescription or doctor prescribed over the counter medications your child is using
Por favor, indique los medicamentos recetados o de venta libre que su hijo esté utilizando
Physician and Medical Insurance
Emergency Contact / Contacto de emergencia:
I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the Youth Ministry office has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment which a physician deems necessary for the well-being of my child.
I certify that the information provided in this document is true and accurate to the best of my knowledge.
Me comprometo a recoger a mi hijo enfermo o lesionado de manera oportuna cuando se me contacte. Si no puedo ser contactado, los contactos de emergencia arriba mencionados pueden ser llamados para recoger a mi hijo. Además, si no se puede contactar conmigo en caso de emergencia, la oficina de la Pastoral Juvenil tiene mi permiso para llevar a mi hijo a la sala de emergencias del hospital más cercano y por la presente autorizo a su personal médico a proporcionar el tratamiento que un médico considere necesario para el bienestar de mi hijo.
Certifico que la información proporcionada en este documento es verdadera y exacta a mi leal saber y entender.
COVID-19 REQUIRED AGREEMENT FOR YOUTH MINISTRY PARTICIPANTS / CONVENIO DEL COVID-19 PARA LOS JOVENES
Because of our current pandemic, all youth ministry participants are required to have a signed agreement on file.
Parents/legal guardians, please read, fill out, and sign the agreement below. Thank you for your understanding!
Parish Name: St Leo the Great Catholic Church
Event Name: 8th Grade Confirmation Retreat
Timeline: October 2nd, 2021.
COVID-19 Youth Waiver in Spanish
ASSUMPTION OF RISK
The novel coronavirus and its variants that cause COVID-19, have resulted in a worldwide pandemic and are contagious. In order to continue in-person ministry, the parish named above ("Parish") has established essential health and safety measures. The Parish has put in place precautionary measures and standards of behavior to reduce the spread of COVID-19 in Youth Ministry activities. These measures and standards may be updated during the ministry year.
Even with implementation of health and safety protocols, however, the Parish and the Catholic Diocese of Arlington cannot guarantee that you or your child(ren) will not become infected with COVID-19. Attendance at the Parish and participation in Youth Ministry activities could increase your risk and/or your child(ren)'s risk of contracting COVID-19. Any interaction with others may result in exposure to, and illness from, communicable diseases including COVID-19.
I understand that Youth Ministry activities are not mandatory. By sending my child(ren) for in-person Youth Ministry activities, I give my informed consent for me or my child(ren) to participate and assume responsibility for the above-noted risks.
I willingly agree that my child(ren) and I will comply with the health and safety protocols established by the Parish, including any future modifications to those protocols, and will take all reasonable and necessary additional precautions to protect against communicable diseases while on Parish premises, not only for our own benefit but for the benefit of others with whom we may come into contact. We agree that, if we observe any objects, practices or procedures we believe to be hazardous while on Parish premises, we will remove ourselves from the location of such hazard and bring it to the attention of Parish administration immediately.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren) and/or I may be exposed to or infected by COVID-19 by participating in in-person Youth Ministry activities, and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the above-named Parish may result from the actions, omissions, or negligence of myself, my child(ren) or others, including, but not limited to Diocesan or Parish administrators, employees, volunteers, and other program participants and their families.
I further agree on behalf of myself and/or my child(ren) named herein, and our respective heirs, successors, and assigns, to fully and forever to release, defend, indemnify, and hold harmless the Catholic Diocese of Arlington, the named Parish, the associated Parish school, their clergy, administrators, employees, agents, members and volunteers ("Indemnitees") from any and all claims, damages, demands, and causes of action, present or future, known or unknown, anticipated or unanticipated, in any way related to exposure to COVID-19 while participating in Youth Ministry activities, including but not limited to any claims of negligent exposure. This includes claims that arise from my own and others’ acts, actions, activities and/or omissions, excepting only those which arise solely from the gross negligence, recklessness or intentional torts of Indemnitees, and those that are both (a) not asserted by our child or family or any member thereof, and (b) not alleged to arise from our acts or omissions. With respect to claims alleged to arise from our acts or omissions, our agreement to defend, indemnify and hold harmless the Indemnitees shall be effective only in the event that I, my child, or a member of our family is determined to be liable for such acts or omissions under applicable law, or by agreement. I will defend and indemnify Indemnitees with respect to any released claim, including but not limited to damages, costs and attorney's fees.
RESPONSIBILITY FOR HEALTH SCREENING
By execution of this Statement, I affirm that my or my child(ren)’s presence at named Parish on any day constitutes an affirmative representation on my part that I/we have performed all health screening steps required by the Parish for attendance or participation in Youth Ministry activities.
I understand that on any day when my child(ren) does not pass the required health screening (which may include questions relating to other members of the household as well as my child(ren)), I and/or my child(ren) are not permitted to participate in in-person Youth Ministry activities.
NEED TO INFORM AND QUARANTINE
I understand, in the event that I/my child is suspected or confirmed positive with COVID-19 or has come in close contact with a person suspected or confirmed positive with COVID-19, I/my child will need to follow the CDC’s guidance for isolation or quarantine as implemented by the Virginia Department of Health and local health departments. Information is available at www.cdc.gov. I agree to inform the Parish administration as soon as possible, but no later than one (1) business day, after learning of my/my child's suspected or confirmed positive case of COVID-19 and/or the need to quarantine due to close contact with a person suspected or confirmed positive for COVID-19.
I understand that I/my child may not return to in-person Youth Ministry activities until approved by Parish Administration. Approval will be based on confirmation by the local health department that the CDC's criteria to discontinue home isolation or quarantine has been met.
AUTHORIZATION AND INFORMED CONSENT
I hereby authorize the Parish to enforce such other reasonable measures and directives as may be deemed necessary by the Bishop of the Diocese of Arlington, its Office of Youth, Campus, and Young Adult Ministries, or the Parish leadership. I further understand that, in the event that, in the event that it becomes necessary that events or programs should be cancelled or administered via electronic media, I will not be entitled to a refund of any of my fees.
This Agreement has been prepared in the English language, and the English version thereof shall prevail and be binding in the event of any inconsistency even though a Spanish or other language translation may also be prepared.
By execution of this Statement, I understand and agree to the foregoing terms and conditions.
REGISTRATION FEE / COSTO DE REGISTRACION
1 Student: $35
2 Students: $40
(Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)
Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!