One form must be filled out for each teenager participating.
**This form is a supplement for all other required ST ROSE OF LIMA waivers unless otherwise noted**
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Please Select All That Apply
Please provide first and last name, phone number with area code and current email address of the person who is the primary legal guardian/custodian.
How do you want us to communicate with you when it comes to important information about youth ministry? Select all that apply
I hereby grant permission for St. Rose of Lima Church to use the image and likeness of my child. I acknowledge that this image and likeness may be used for, but not limited to: parish website, social media, St. Rose of Lima Church and its ministries and programs.
I hereby grant permission for the Youth Minister and its subsidiaries of St. Rose of Lima Church to contact my child via the methods expressed below for the purpose of communication for youth ministry program only. This information will only be used for the purposes of communication related to youth ministry, and will not be released to any other parties or used for any other purposes.*
*St. Rose of Lima Church Youth Ministry follows the VIRTUS Safe Environment guidelines and rigorously abides by Syracuse Diocese Circles of Care Policies.*
For a copy of the Syracuse Diocesan Child & Youth Protection Policy, please visit: https://www.syracusediocese.org/safe-environment/diocesan-child-and-youth-protection-policy/
I hereby grant permission to my child being transported via private transportation. This can include transportation with VIRTUS trained volunteers, parents and parish staff. I also consent to my child traveling via approved rented or chartered transportation such as approved rental vehicles or chartered bus.
By consenting to this, I do not hold St. Rose of Lima Church, its volunteers or staff, or the Diocese of Syracuse, liable for any accident or injury that may occur
Please list any food or medicinal allergies or restrictions, as well as any pertinent medical information concerning your teen.
This waiver/consent ONLY applies in the event that neither parent/guardian can be reached in the case of an emergency.
I hereby authorize all medical and surgical treatment, X-ray, laboratory procedures, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I also consent to any ambulatory transportation needed in the event of an emergency.
I also consent to the administration of any basic medicines needed in non-emergency situations, such as ibuprofen/acetaminophen for pain, antihistamines for allergies or other over the counter medicine to treat non-emergency symptoms.
In the event of any emergency, I wish for the authorities to the following action:
By typing a name here, I acknowledge that I have provided correct information and understand any consent I have given.
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