SERVE Registration – St. Leo the Great Youth Ministry

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Cell Phone *

Parent/Guardian Work Phone

Relationship to teen?

SAFETY *

As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

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PARENTAL PERMISSION AND LIABILITY RELEASE *

As parent/legal guardian of the participant names above, I give my permission to participate fully in SERVE 2022 at St. Leo the Great on July 10-13, 2022. The meeting time will be The St. Leo Gym on July 10 at 6:00pm-8:00pm and July 11-13 at 8:30am-8:00pm; pick up time is always 8:00pm. I also give permission for my child to stop at one of the following on “7 Eleven” convenient stores on July 11 for a free slurpees (3910 University Dr. 10140 Fairfax Blvd, or 10485 Fairfax Blvd, Fairfax, VA 22030). I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.

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INFORMED CONSENT TO MEDICAL TREATMENT *

I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

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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.

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MEDICATIONS