I (We), _____________________________and __________________________, the parent(s)/ legal guardian(s) of ___________________________ give my child permission for him/her to participate in the following sports program:_______________________________which will take place at _______________________________ on _______________(month/day/year).

I give permission for my child to be transported to and from this activity under the following conditions:

My child may (please initial):

______ ride with a driver 18 years or older only

______ ride with an adult 21 years of age or older

______ drive his/her own vehicle/family car

______ transport other youth.

I(We) will instruct my child about my(our) choice above and he/she will be responsible to comply with it.

I (We) understand that in the event of an accident the driver/owner's insurance carrier is the primary source, and the Archdiocese of Miami provides coverage, but only as a secondary source.

In the event of an emergency, I (We), hereby give permission to transport my child to a hospital for emergency medical, dental, anesthetic or surgical treatment. I(We) wish to be advised prior to any non-emergency treatment by the hospital or doctor. I (We) agree to pay for any expenses incurred for such treatment.

I (We), individually and in my(our) capacities as parent(s)/legal guardian(s) 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, and liability arising out of my child's participation in the program.

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

___________________________

Signature

___________________________

Signature

___________________________

Date

Name: ___________________________________Birth Date: ___________________

Address: _____________________________________________________________

City: _______________________ State: ______Zip Code: _______________

Home Phone Number: ________________________

Name of Father/legal guardian: __________________ Work Phone No.: ________________

Name of Mother/legal guardian: __________________ Work Phone No.: ________________

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:______________________________________________________________

_________________________________________________________________________

Form 9. (Rvsd. 9/4/98)