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Form E

- Youth

Form E-Adult Consent and Waiver

CONSENT TO TREATMENT: I hereby warrant that to the best of my knowledge, I am in good health and physically able to participate in the Activity and I assume all responsibility for my health and physical condition and my ability to participate. In the event of circumstances that indicate that I am in need of immediate medical care, I authorize and give permission for myself to be transported to a hospital/clinic/medical facility for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination. I authorize any licensed physician or medical center to treat me. I accept full responsibility for any associated medical or hospital bills.

LIABILITY WAIVER In consideration of my participation in the Activity (ies) set forth by Cathedral of Our Lady of Perpetual Help and Bishop John Carroll Cathedral School. I do on behalf of myself and my heirs, successors, assigns and next of kin, release, waive, hold harmless, defend and covenant NOT TO SUE, Cathedral of Our Lady of Perpetual Help, Bishop John Carroll Cathedral School, the Archbishop of the Archdiocese of Oklahoma City, and the Archdiocese of Oklahoma City and each of their respective departments, directors, administrators, teachers, officers, agents, representatives, volunteers and employees from any and all actions, claims, demands or liabilities, including without limitation, those for personal injuries or property damage, that I may suffer due to illness or injury suffered as a result of, or in connection with, participation in the Activity, including without limitation, travel to and from the Activity, housing, meals and collateral entertainment and medical treatment and any consequences that may arise as the result of said treatment, to the fullest extent permitted by law.

LOST OR STOLEN ITEMS: I hereby understand and agree that neither Cathedral of Our Lady of Perpetual Help, Bishop John Carroll Cathedral School, nor the Archdiocese of Oklahoma City nor any of their respective departments, employees, directors, officers, agents, representatives and/or volunteers shall be held liable for any of my personal property lost or stolen during participation in the Activity.
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- Name of Activity REQUIRED Please fill out this field. Please enter valid data.
- Participant's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Birth Day (Month, Day, Year) REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- T-shirt size
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Home Phone Number Maximum 20 characters Please enter a phone number.
- Work Phone Number Maximum 20 characters Please enter a phone number.
- Name of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- MEDICAL INFORMATION: List any medical conditions (e.g., diabetes, epilepsy, heart conditions, etc.) Explain (email person overseeing activity if additional space is needed to submit complete medical info): (If None, type None) REQUIRED Please fill out this field.
- I am taking the following medications: (If None, type None) REQUIRED Please fill out this field.
- Do you have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED Please fill out this field.
- If yes, explain: (email person overseeing activity if additional space is needed to submit complete allergy info)
- Do you have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) REQUIRED Please fill out this field.
- If yes, explain: (email person overseeing activity if additional space is needed to submit complete adverse reaction info)
- Do you have any disabilities or physical or developmental limitations? REQUIRED Please fill out this field.
- If yes, explain: (email person overseeing activity if additional space is needed to submit complete list of limitations info)
- Date of last tetanus immunization: Month/Year REQUIRED Please fill out this field. Please enter valid data.
- Participant's Primary Physician Please enter valid data.
- Physician's Phone Number: Please enter valid data.
- Health Plan Carrier Please enter valid data.
- Health Plan Carrier Group# Please enter valid data.
- Health Plan Carrier Policy# Please enter valid data.
- Name of primary insured on Health Plan Please enter valid data.
- Signature REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- I understand that checking box below constitutes that the above is a legal signature, all the above information is true and I have read and understand this consent and waiver form & sign it voluntarily and entirely of my own free will.
  Acknowledgement of statement above, Please select this field.
- Email for Receipt REQUIRED Please fill out this field. Please enter an email address.
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