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.
Parent Statement of Responsibility
My son/daughter has my permission to attend St. Basil Life Teen retreat to be held at Hiram House Camp, in Chagrin Falls, OH. Life Teen Core Members will serve as adult chaperones for the trip. Teens will be transported by bus to and from the retreat. No students are allowed to drive to the retreat. Participants are required to stay the entire time. I support the right of the group’s leaders to have me come & pick up my teen at any time if given just cause. I have read and understand the “To Bring/Not to Bring” list. The undersigned hereby gives approval for my child to participate and does waive, release, save and hold harmless and indemnify St. Basil the Great, Life Teen Core Members, organizers and agents from any personal injury to my child.
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.