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 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 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 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.
- COVID-19 Consent and Waiver
  
  The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Orangization. COVID-19 is extremely contagious and as a result, social distancing is recommended. St. Catherine of Siena will follow state and local standards of conduct and has put in place reasonable preventative measures to reduce the spread of COVID-19 at its parish activity. However, even though such standards will be followed and reasonable measures put into place, St. Catherine of Siena cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the St. Catherine of Siena activity could increase your risk and your child(ren)'s risk of contracting COVID-19.
  
  By signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren) and I may be exposed to or infected by COVID-19 by participating in the St. Catherine of Siena activity and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at St. Catherine of Siena may result from the actions, omissions, or negligence of myself and others, including, but not limited to St. Catherine of Siena employees, volunteers, and program participants and their families.
  
  Considering the foregoing, however, I grant permission for my child to participate in St. Catherine of Siena activities that may require transportation to a location away from St. Catherine of Siena, notwithstanding the risks associated with the COVID-19 virus and group activities.
  
  I confirm that there are no necessary changes to the Medical Release and Waiver form for my child that I previously submitted. If there are any necessary changes, I will complete another Medical Release and Waiver form.
  
  I further agree on behalf of myself, my child named herein, and my spouse, our heirs, successors, and assigns, to release, indemnify, hold harmless, and defend St. Catherine of Siena, their members, directors, officers, employees, agents and representatives ("indemnitees") associated with the event arising from or in connection with the negligent acts or omissions of indemnitees' in relation to prevention of the spread of the COVID-10 virus. I SPECIFICALLY ACKNOWLEDGE AND AGREE THAT I AM AGREEING TO DEFEND, INDEMNIFY AND HOLD HARMLESS THE INDEMNITEES' FROM THEIR OWN NEGLIGENCE IN REGARD TO THE INDEMNITEES' NEGLIGENT ACTION AND/OR INACTION IN REGARD TO PROTECTION AGAINST THE COVID-19 VIRUS.
  I Agree Please select this field.
- 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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