I/we the parent (s) or legal guardian (s) of above mentioned teen do hereby give my consent for Tim Dollard or other official adult representative of the St. Basil youth program, in the event that all reasonable attempts to contact me at the numbers provided have been unsuccessful, to seek medical attention and treatment as deemed necessary.

This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists concur in the necessity for such surgery and are obtained before surgery is performed.

Further, and unless specified otherwise, consent/permission is hereby given to Tim Dollard, and all accompanying adult chaperone leaders on this trip to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personnel).

I agree that my insurance company will be used for such medical care expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any medical bills.

Any and all information concerning the above named child’s history including allergies, medications and physical impairments, has been reported in these registration forms. In the event of an emergency, I authorize the St. Basil youth program to share the completed registration information packet with persons related to the treatment of the above named program member.

As a participant in the Life Teen program, I hereby give St. Basil Church, and the Life Teen program my permission to use the above applicant’s likeness in photo or video form and his/her name in publicity, both within internal communication of the above-mentioned groups for use in communication pieces, and to area news media in all forms without limit as to time. I further release them from liability for what I might deem a misrepresentation of him/her by virtue of alterations, optical illusions, or faulty mechanical reproduction.