PERMISSION TO PARTICIPATE IN ACTIVITIES
2018-2019 RC Activities, Inc.
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  • 2. NATURE AND DURATION OF ACTIVITIES

    Oct. 5-7, Dec 7-9, Feb 22-24; April 5-7; Prayer, Mass, Virtue talks, sports, skits, team building, bonfire, night games.
  • 3. ACTIVITY SUPERVISOR(S)

    Legionaries of Christ and other adult chaperones.
  • 4. TRANSPORTATION

    Not Applicable. Participants are responsible for securing their own transportation to and from activities, as the company does not provide transportation.
  • 5. MENTORING

    Participants may be offered mentoring, which is intended to help young people personalize the principles of Christian living that they receive at home and in club activities. Mentoring involves a private conversation with an adult conducted in plain view of others. When dealing with adolescents, confidentiality will be maintained to foster an openness of dialogue, but situations involving sexual abuse of a minor or threats to life or physical health will be reported to the appropriate authority and to the parents (except in those cases where the parent may be the alleged abuser).
  • 6. REQUIREMENTS

    The child named above is in good health and has no physical or medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify allergies and medical problems in section 10 below.
  • 7. CONSENT

    I/We hereby consent to the above-named child's participation in the activities described above including mentoring, and specifically request that he be allowed to participate in those activities. I/We warrant that I/We have full authority to legally consent to his participation in the activities described on this form, and all provisions contained herein.
  • 8. AUTHORIZATION

    I/We hereby authorize RC Activities, Inc. to use the image and likeness of my/our child in photograph or video form whether taken by or commissioned by RC Activities, Inc. in its promotional materials and for its promotional purposes associated with its nonprofit activities. This authorization shall extend to use of my/our child’s image and likeness on the website of RC Activities, Inc., or its successor in operation or affiliated organization(s) upon written consent of RC Activities, Inc. I/We understand that this authorization shall survive the end of my/our child’s participation in the activities referenced on this form.
  • 9. INSURANCE

    I/We understand that RC Activities, Inc. does not carry any health insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my/our own insurance carrier; or (b) that I/We am/are personally financially responsible for any and all medical costs incurred as a result of the child's injury.
  • 10. EMERGENCIES

    If the above-named child requires any emergency medical procedures or treatments during the activities, I/We consent to the activity supervisor(s) taking, arranging for or consenting to such procedures or treatments in the discretion of the activity supervisor(s). For purposes of such procedures and treatments, my/our child's blood type allergies or other medical problems (if any) are listed below:
  • 11. EMERGENCY CONTACTS

    If, in the event of a medical or other emergency, I/We am/are unable to be reached by telephone at the numbers listed below, I/We authorize the activity supervisor(s) to attempt to contact me/us through the alternative emergency contacts listed below.
  • Parents/ Guardians Contact Information

  • Email address
  • - -
    Phone
  • - -
    Alternate Phone
  • Email address
  • - -
    Home Phone
  • - -
    Alternate Phone
  • Alternative Emergency Contact Information

  • Relation
  • - -
    Phone
  • - -
    Alternate Phone
  • 12. COMMUNICATION (*not applicable for campers under the age of 15)

    I give permission for Event Supervisor(s) and Club Leader(s) to communicate with my child using text messaging and/or email regarding the details of all related activities and programs:
  • - -
    Child's cell
  • - -
    Parent's cell
  • Child's email
  • Parent's email
  • 13. RELEASE AND INDEMNIFICATION

    I/We release and waive, and further agree to indemnify, hold harmless or reimburse RC Activities, Inc. and Consolidated Catholic Administrative Services, Inc., the individual members, agents, directors, officers, employees, volunteers and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses (including attorneys’ fees incurred by RC Activities, Inc. and Consolidated Catholic Administrative Services, Inc., or any of its individual employees, agents, volunteers, etc. in enforcing this indemnity provision) without limitation in time or amount, damages or injuries arising out of, during, or in connection with my/our child's participation in the activities, the travel to and there from, and the rendering of emergency medical procedures or treatment, if any. I/We understand that this release and indemnification shall survive the end of my/our child’s participation in the activities referenced on this form and shall have no limitation in time or amount.
  • 14. BOCAMB INSURANCE

    I/We understand that Bocamb Farm does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is covered by insurance through my own insurance carrier.
  • 15. BOCAMB RELEASE AND INDEMNIFICATION

    I/We release and waive, and further agree to indemnify, hold harmless or reimburse Bocamb Farm against any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses (including attorneys’ fees incurred by Bocamb Farm or any of its owners, employees, agents, volunteers, etc. in enforcing this indemnity provision without limitation in time or amount, damages or injuries arising out of, during, or in connection with the child’s participation in the activities, the travel to and there from, and the rendering of emergency medical procedures or treatment, if any. I/We understand that this release and indemnification shall survive the end of my child’s participation in the activities at Bocamb Farm referenced on this form.
  • 16. AUTHORIZATION TO GIVE MEDICATION

  • • PRESCRIPTION MEDICATIONS must include signature authorization from the child's physician. Prescription medications will NOT be administered without physician consent.
    • OVER-THE-COUNTER MEDICATIONS require parent authorization only.
    Medications must be in the original labeled container (no baggies, foil, etc.). Pharmacists can provide a duplicate labeled container.
    • Parent/guardian must provide the medication, related equipment required and specific instructions. The child MAY NOT bring these materials to camp or Mission Network Activities USA, Inc. activities.
    • Medication changes or dosage changes must be noted on a NEW medication authorization form. It is the responsibility of the parent/guardian to inform the Mission Network Activites USA, Inc Club Volunteer or any changes.
    • New medication or dosage changes will not be given unless a newly labeled container is provided.
    • Unused medication will be disposed of unless picked up within one week after medication is discontinued.
    • Medication will be administered as follows:
  • Name of Medication
  • Dose
  • Administration Time
  • Route (by mouth, topical, etc.)
  • Stop medication on
  • Illness/Symptoms in which child may require medication as necessary
  • Additional equipment required for administration
  • Possible side effects
  • Physician's Name
  • - -
    Physician Phone
  • By completing and submitting this Agreement and checking the “I agree” box, you are consenting to the terms and provisions, as well entering into this Agreement in electronic form. You hereby agree that the accompanying electronic signature is valid for all purposes, as defined by law.