ARCHDIOCESE OF CINCINNATI

PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY  

1.  I, the lawful parent or guardian of                                                              (the “child”), give permission for my child to participate in Vacation Bible School on July 28-August 1, 2008, at Precious Blood Church, Trotwood, OH, and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.  

  2.  I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity.

  3a.   I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel:  

(i)  To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child.

         (ii)  I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.  

3b. This power of attorney shall lapse automatically upon completion of the activity and related travel.

4.   I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes, website and office functions.

       I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning.

Signature of Parent or Guardian___________________________________________________       Date        /         /            

Address_______________________________________________ City____________________________ Zip __________

Place of Employment__________________________________________________________________________________

Address_______________________________________________ City ___________________________ Zip___________

Phone: (w) _________________(h)__________________  Social Security # (optional)_____________________________

Emergency Contact ___________________________ Phone: (w or cell) ___________________ (h)__________________

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Medical Information — Completed by Parent or Guardian — Please Print  

Child’s Name                                                                                                 Birth date_______________________________

Allergies_____________________________________ Medications  ___________________________________________ 

Chronic Conditions (e.g. epilepsy, diabetes)    ____________________________________________________________                                                                                                   

Medical Insurance Co.                                                                                   Policy No.  _____________________________                             

Member's Name_________________________________  Phone: (h) ___________________ (w)_____________________

Family Physician  __________________________________________ Phone ____________________________________