Emergency Contact Name(other than parents)

• Medical and Photo Release

• As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Catholic Diocese of Richmond, the Holy Spirit Catholic Church, their employees and agents, chaperones, or representatives associated with the event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese and/or Holy Spirit Catholic Church, their employees and agents and chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese and/or Holy Spirit Catholic Church.

• I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to Holy Spirit Catholic Church to contact emergency services for the transportation of my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold the Diocese of Richmond and/or the Holy Spirit Catholic Church responsible for authorizing any medical treatment beyond necessary transportation to the hospital.

By checking this box you are stating and agreeing that all the above information is correct and agree to the terms listed above.

• I give permission for pictures and/or video of my child(ren) (named above) engaged in activities related to the Holy Spirit Catholic Church to have their pictures posted in publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, Holy Spirit Catholic Church assumes you give permission.