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Archdiocese of Dubuque
Annual Parental/Guardian Consent Form and Liability Waiver

This Consent Form and Liability Waiver is required for and serves both on-site programs and offsite/
field trip events/activities for the stated program year. This form needs to be completed annually for
each student. To obtain the needed permission, contact, emergency and medical information you are
requested to supply the needed information. As the specifics of each off-site/field trip event are known
you will be required to complete an Off-site/Field Trip Permission Form outlining the specifics of each
activity. Please complete all sections.
The maximum number of form submissions has been reached. This form is currently not available.
- Section 1 - Contact Information
- Student/Participant's Name: REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Male Female Please fill out this field.
- Parent/Guardian's name: REQUIRED Please fill out this field. Please enter valid data.
- Home Address: REQUIRED Please fill out this field. Please enter valid data.
- Home/Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Business/Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Section 2 - Off-site/Field Trip Consent Form and Liability Waiver
- I,
- Parent or Guardian's Name: REQUIRED Please fill out this field. Please enter valid data.
- Grant Permission for my child,
- Name of child REQUIRED Please fill out this field. Please enter valid data.
- to participate in school/parish
  events this year that may require transportation to a location away from the school/parish site. The activities will take place under the guidance and direction of school/parish employees and/or volunteers of the Cathedral of St. Raphael and St. Patrick Church.
  
  As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“ Participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend, its officers, directors of Cathedral of St. Raphael and St. Patrick Church and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events, arising from or in connection with my child attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events for reasonable attorney’s fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Archdiocese of Dubuque.
- Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
- Date (d/m/y) REQUIRED Please fill out this field. Please enter a date.
- Section 3 - Specific Medical Matters
- 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.
  Item A - Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport 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, contact:
- Name and Relationship REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Family Doctor REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
- Policy # Please enter valid data.
- Item B- Other Medical Treatment
- In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I want to be notified.
- I want to be notified. Yes No
- If Yes, Please Call Please enter valid data.
- On-site Nonprescription Medication Permission - I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at the on site program.
- I grant permission. Yes No
- Item C - Specific Medical Information:
  The parish/school will take reasonable care to see that the following information will be held in confidence. Check/explain all that are applicable to this student/participant.
- Allergic reactions (medications, foods, plants, insects, etc.) If none write NA REQUIRED Please fill out this field. Please enter valid data.
- Utilizes asthma or airway constricting prescription medication (see item 9.3 below) - If no, write NA REQUIRED Please fill out this field. Please enter valid data.
- Has a medically prescribed diet? If not applicable write NA REQUIRED Please fill out this field. Please enter valid data.
- Any physical limitations? If not applicable write NA REQUIRED Please fill out this field. Please enter valid data.
- You should be aware of these special medical conditions of my child. If not applicable write NA REQUIRED Please fill out this field. Please enter valid data.
- Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
- Date (d/m/y) REQUIRED Please fill out this field. Please enter a date.
- THIS FORM REPLACES PREVIOUS VERSIONS AS OF DATE SIGNED
  
  Administration of Medication - Archdiocesan Board of Education Policy 5141, items 9-10.
  9. Dispensing of prescription medication
  
  1. For Catholic schools - Dispensing of prescription medication will be administered by a nurse or designated party with training and with the written consent of parent(s)/guardian(s). Prescription medication must be provided to the
  school in the original labeled container containing the physician’s name, name of the medication, and dosage/frequency to be given. A record of each dose of medication administered will be documented in the pupil’s health record.
  
  2. For all other youth programs - Dispensing of prescription medication will be self-administered by the child if a written consent of parent(s)/guardian(s) accompanies the prescription medication and the following terms are followed. The prescription medication is provided in the original labeled container containing the physician’s name, name of the medication, and dosage/frequency to be given; the prescription medication is turned into the event supervisor who will hold all medication until the child/youth requests the medication for self-administration, the prescription medication is self-administered in the presence of the adult supervisor and for only the dosage stated on the prescription label.
  
  3. Students utilizing asthma or airway constricting prescription medication are allowed to administer their own dosage provided a completed consent form is on file in the school/program office. Such forms must be filed annually.
  
  4. Contraceptives will not be dispensed. Iowa Code §280.16
  
  10. Dispensing of nonprescription medication may occur, provided the parent/guardian have signed and dated an authorization identifying medication, dosage, and time interval to be administered. Nonprescription medications can be provided on off-site field trips if the parent/guardian signs a nonprescription medication authorization for each off-site field trip.
- Please type STPR231! to prove you are a human: REQUIRED Please fill out this field. Please enter valid data.
Submit

Cathedral of St. Raphael &
St. Patrick Church

Dubuque, IA

OSE Annual Consent Waiver

Section 1 - Contact Information

Section 2 - Off-site/Field Trip Consent Form and Liability Waiver

Section 3 - Specific Medical Matters

Item B- Other Medical Treatment

Item C - Specific Medical Information:

THIS FORM REPLACES PREVIOUS VERSIONS AS OF DATE SIGNED