Child & Youth Protection - Diocese of Orlando Policies on Child Sexual Abuse

Waivers and Releases

Sample Form Download

Sample Field Trip Form
field_trip.pdf (22k - Acrobat Reader required)

Sample Medical Information Form
medical_info.pdf (13k - Acrobat Reader required)

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Sample Form

DIOCESE OF ORLANDO FIELD TRIP PERMISSION FORM AND RELEASE OF LIABILITY FOR (inset name of SCHOOL/PARISH)

I am the parent/guardian of ________________________, and give my permission for my child to travel in ______________________ (MODE OF TRANSPORTATION) to attend the field trip to _________________________________ ("the event") on __________(DATE).  I acknowledge that the (SCHOOL/PARISH) is responsible for transportation only from the Church's property to the event, and that I must bring my child to the (SCHOOL/PARISH) and pick my child up after the event.  My child also must comply with the (SCHOOL'S/PARISH'S) field trip rules and procedures. By granting this permission, I also waive any claims against, and release and hold harmless, (SCHOOL/PARISH), the Diocese of Orlando, and any of their religious, employees, volunteers, agents, and representatives, from any harm that occurs to my child while participating in the field trip.

 In the event my child requires medical treatment or transportation for medical care, (SCHOOL/PARISH) will attempt to contact me at the number(s) listed below.  If they are unable to reach me, (SCHOOL/PARISH) may contact the designated emergency contact at the number(s) listed below.  If the chaperones, volunteers, or other adult supervisors are unable to reach the designated emergency contact, I authorize them to take appropriate measures to provide care and treatment for my child, to transport my child to the nearest emergency room or physician's office, or to call an emergency paramedic ambulance service.

Parent/Guardian's Signature ___________________________________ Date _____________

My Child is covered by the following medical insurance:

Insurance Co. Name:_____________________________________Group #_________________

Allergies:_______________________________Chronic/Acute Illnesses:___________________

(OR740814;1)

Sample Form

MEDICAL INFORMATION FORM

Child's Name: ___________________________________

Parent/Guardian: _________________________________

Allergies to Medication:

Chronic or Acute Illnesses:

Medication Presently Being Taken:

Other Facts we Should Know: sp;

Does your child have a medical condition that limits them in participating in any of the field trip activities? ______ Yes ______ No

If Yes, you must provide documentation from a physician advising of the limitations before your child may attend the field trip.

Does your child need to take medication while on the field trip? ______ Yes _____ No

If yes, you must provide a physicians note with adequate instructions for administering the medication and the medication must be in its original container marked with your child's name. In addition please read the following paragraph and initial below:

I give my permission to the chaperones, volunteers, or other adult supervisors, to administer the above-referenced medication to my child, and I release and hold harmless (SCHOOL/PARISH), the Diocese of Orlando, and any of their religious, employees, teachers, volunteers, agents, and representatives from any injury or harm resulting from administering the medication.

Initials  __________________.

I acknowledge that all of the information provided is true and correct and will only be disclosed to the chaperones, volunteers, or other adult supervisors attending the field trip and any medical providers as needed.