Saint Catherine of Siena

Wichita, Kansas

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Forms and Waivers

- Hospitality

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- Medical Release and Waiver
  (revised February 2020)
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- School Grade REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Height REQUIRED Please fill out this field. Please enter valid data.
- Weight REQUIRED Please fill out this field. Please enter valid data.
- 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.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Emergency Contact #1 REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Participant Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Emergency Contact #2 REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Participant Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Insurance Company REQUIRED Please fill out this field. Please enter valid data.
- Policy # Please enter valid data.
- List Allergies/ Present medical conditions/ activity and/or food restrictions: REQUIRED Please fill out this field. Please enter valid data.
- List current Medications and dosage: REQUIRED Please fill out this field. Please enter valid data.
- Does Participant wear contact lenses? REQUIRED Please fill out this field.
- Medical Authoization
  I/We understand that the Catholic Diocese of Wichita and St. Catherine of Siena assume no responsibility for accidents which may occur in association with diocesan events and activities. I/We agree to use my/our personal insurance to cover any such incidents. I/We understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia or surgery for Participant as deemed necessary.
  I Agree Please select this field.
- Waiver
  I understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Wichita and St. Catherine of Siena and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Catholic Diocese of Wichita and/or St. Catherine of Siena, its leaders, employees and volunteer staff from any claim arising from or in connection with attending this event.
  I Agree Please select this field.
- Code of Behavior
  I agree to abide by and/or instruct Paricipant to abide by all rules and regulations outlined by the aforementioned chaperones/representatives. I agree that if I/Paricipant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the trip/event and sent home immediately at my/Participant's expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Wichita and/or St. Catherine of Siena.
  I Agree Please select this field.
- Photo Release
  I hereby authorize St. Catherine of Siena, and its agents to utilize photographic and/or video images of me or my child by St. Catherine of Siena. In giving my consent, I hereby indemnify and hold harmless the Catholic Diocese of Wichita and its agents from any and all responsibility or liability. I understand that I will receive no compensation, should any photograph and/or video of me or my child be used.
  I Agree Please select this field.
- Signature of Participant REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- Signature of Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
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Forms and Waivers

Medical Release and Waiver (revised February 2020)

Medical Release and Waiver
(revised February 2020)