CCC Health and Release Form – Cincinnati Cathedral

Participant Full Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Participant Phone *

Parent/ Guardian Phone *

Personal Physician *

Physician Phone *

Health Insurance Company *

Company Phone *

Policy # *

Insured ID # *

Prescription Card # *

Emergency Contact Name *

First

Last

Relationship *

Daytime Phone *

Evening/Night Phone *

Allergies (food, animals, etc.) *

Medications participant cannot take: *

Medications participant currently takes, and how/when they are to be administered: *

Release Terms & Conditions *

This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

This participant is expected to follow all guidelines set for each Christ Church Cathedral event in which s/he participates. Permission is given by the participant and her/his parent(s)/guardian(s) for Cathedral representatives to transport the participant as necessary for official Cathedral Youth Program activities. Consent is given by the participant (and her/his parent/guardian) for photographs of the participant to be taken during Cathedral Youth Program Events with the understanding that no minor will ever be identified in such photos in any Christ Church Cathedral publication without express written consent of a parent/guardian. Cathedral Youth Program events, for which this health and release form are used, may involve physical activities (running, sports, supervised minor construction, etc.). Such activities are optional, and no participant will be required to participate in any of these activities against their will. This participant and her/his parent(s)/guardian(s) release Christ Church Cathedral, its agents, employees, and any and all persons connected therewith from any and all liability, claims, and causes of action of any type whatsoever arising out of or in any way connected with participation in official Cathedral Youth Program Activities.
Consent/Permission is given for the participant to be treated by competent medical personnel in the event of an accident or medical emergency and to receive reasonable medical treatment as deemed necessary by a licensed physician.
In the event that treatment is called for which a physician and/or other professional health care provider refuses to administer without the consent of a parent/guardian, and no parent/guardian is readily accessible by phone, we hereby authorize Christ Church Cathedral's director of Youth Ministry to give such consent.