Permission to Participate in Hurricane Relief
2020 RC Activities, Inc.
  • *No minors allowed to come without parent*

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  • 2. NATURE AND DURATION OF ACTIVITIES

    September 12-13, 19-20, 26, and October 3, 10, 17, 2020, @ Lake Charles: Consists of removing downed trees, cleanup of debris and house/church damage.
  • 3. ACTIVITY SUPERVISOR(S)

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

    Not applicable. Each missionary must provide own transport.
  • 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.
  • Parent/Guardians Contact Information

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

  • Relation
  • - -
    Phone
  • 12. COMMUNICATION

    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 the Activity / Program (*Only participants 15 years old and older*).
  • - -
    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.
  • 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
  • Illness/Symptoms in which child may require medication as necessary
  • Physician's Name
  • - -
    Physician Phone
  • 17. ASSUMPTION OF COVID-19 RISK AND WAIVER OF LIABILITY

    I acknowledge [for myself and/or my child(ren)] the highly contagious nature of COVID-19, as well as its potential to cause infection, illness, injury, permanent disability, and death. I voluntarily accept and assume the risk that may be exposed to or infected by COVID-19 by visiting/participating/attending the above named event operated by RC Activities, Inc. further accept [for myself and/or my child(ren)] and assume the risk that such exposure or infection may result in my [my child(ren)1 personal injury, illness, permanent disability, and/or death. RC Activities, Inc. cannot prevent you [for yourself and/or your child(ren)] from becoming exposed to, contracting, or spreading COVID-19 while visiting/participating/attending the above named event It is not possible to prevent against the presence of the disease. Therefore, if you [for yourself and/or your child(ren)] choose to visit/participate/attend the above named event you [for yourself and/or your child(ren) may be exposing yourself [your child(ren)] to and/or increasing your risk of contracting or spreading COVID-19 understand that the risk of becoming exposed to or infected by COVID-19 may be increased as a result of the actions, omissions,
    and/or negligence of RC Activities, Inc., including its independent contractors, agents, vendors, guests, and employees.

    I voluntarily assume [for myself and or my child(ren)] all of the risks of COVID-19 and of COVID-19 exposure and accept sole responsibility for any harm to me [my child(ren)] (including, but not limited to, personal injury, illness, permanent disability, and death).

    In consideration of RC Activities, Inc. allowing me onto its premises/visiting /participating/attending the above named event also, on behalf of myself [my child(ren)l and my successors and representatives, waive, release, and forever discharge RC ACtivities, Inc.its agents, employees, officers, directors, contractors, customers, successors, and assigns from any and all claims and causes of action of any kind or nature which are in any way related, directly or indirectly, to COVID-19, which may have or that hereafter may accrue, including any such claims or causes of action caused in whole or in part by the negligence of RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns. [for myself and/or my child(ren)] further agree that will not bring any claim or cause of action against RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns related in any way, directly or indirectly, to COVID-19, and/or any associated personal injuries, illness, disability, or death.

    I [for myself and/or my child(ren)]further agree to indemnify, defend, and hold harmless RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns from any claims or causes of action of any kind arising from my exposure to COVID-19 as a result of visiting/participating/attending the above named event provided by RC Activities, Inc.
  • 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.