I/We the undersigned Parent or Guardian of ________________________________________________ do hereby give my/our permission for my/our child to participate in _____________________________________________ sponsored by __________________________________ at St. Scholastica Church in Aspinwall, PA.
In consideration of the agreement of Youth Ministry to allow my/our child to participate in said activity and intending to be legally bound hereby, I/We agee to indemnify and hold harmless St. Scholastic Church and the employee thereof, the Roman Catholic Diocese of Pittsburgh, the Most Reverend David Zubic, their successors and legal representatives, against any loss from any and all claims, demands and actions at law or in equity that may hereafter at any time be brought by my/our child, or anyone acting on behalf of my/our child as a result of, or in any way related to his/her participation in the above mentioned activity, or his/her thereto.
I/We agree that in case of injury to my/our child, I/We will apply our hospitalization and/or accident insurance toward the payment of the expenses incurred and will not look to St. Scholastica Church or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury related costs.
In witness whereof, I/We execute this Hold Harmless and Indemnification agreement this_____________day of ___________________________20______.
Parent or Guardian (signature)_____________________________________
Street Address, State and Zip Code_________________________________
Contact person if parent/guardian can not be reached___________________________________
Please note in the space provided if your child has any condition, medical or otherwise that the sponsor should be made aware.
List medications: _______________________________________________________
Any dietary concerns, allergies, etc? ________________________________________
Insurance Carrier ____________________________________________________
Group # ___________________________________________________________
ID # _____________________________________________________________
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