I, ______________________________________________________, in the event of an emergency, hereby give permission to be transported to a hospital for emergency medical, dental, anesthetic or surgical treatment. I agree to pay for any expenses incurred for such treatment.

I release, indemnify, and hold harmless the Archbishop of Miami, the Archdiocese of Miami or any parish thereof, its employees, agents, representatives, affiliates, and volunteers from any and all demands, claims, injury, and liability arising out of my participation in the program.

I hereby waive my claim to a lawsuit against the Archdiocese of Miami or any such persons for any liability arising out of my participation in this activity.

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Signature

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Date

Name: ___________________________________Birth Date: ___________________

Address: _____________________________________________________________

City: _______________________ State: ______Zip Code: _______________

Home Phone Number: ________________________

In case of emergency contact:____________________________________________

H. Phone:________________ W. Phone:_________ Relation:__________________

Name of Parish: ___________________________________________

Name of Family Doctor: ________________________Tel. No.: __________________

Do You have Insurance?Yes No Name: ____________________(Attach copy of insurance card)

Policy No.: _______________________ Are you taking any Medication? Yes No

If yes, Type/Name: __________________ Dosage: _________________

Doctor: _______________________ Do you currently have a medical problem or condition?

If yes, explain kind and symptoms:______________________________________________________________

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Form 8 (9/4/98)