Liability Waiver
Benedictine Youth Congress
Atchison, Kansas
July 16 - 18, 2017
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Participant’s Name: Last First MI
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Address: Street City
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State Zip Telephone
Graduation year _______ Age (during camp) _____
School you attend______________________________________________________________________
E-mail: ______________________________________________________________________________
Participant agreement
As a participant in the Benedictine Leadership Conference, being held at Benedictine College, I agree to fully participate and follow all established rules. I understand that I may not bring/use alcohol or illegal drugs at any time during my time at the conference. I will cooperate with the conference organizers and other participants to help make this experience positive for all involved. If I fail to cooperate, I understand that my parents/guardians will be contacted and I may be sent home at my own expense. By signing this form, I agree to the terms listed.
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Participant Signature Date
Participant’s Health Form
to be completed and signed by participant’s parents or legal guardians
Asthma Head Injury/Concussions Bleeding Disorders Heart Disease Convulsions/Seizures Rheumatic fever Diabetes _____________________________________________________
Allergies to Drugs or Foods:__________________________________________________________
Last Tetanus Immunization (date) _____________________________________________________
Current Medications _______________________________________________________________
Chronic or recurring illnesses _______________________________________________________
Physical Restrictions* _____________________________________________________________
Name of Insurance _______________________________________________________________
Telephone Number for claims ___________________________________________
Contract Number _____________________________________________________
Group Number _______________________________________________________
Name of Employer ____________________________________________________
Name of Policy Holder _________________________________________________
Physician name and Telephone _________________________________________
Parent Authorization/Release of Information
This health history is correct to the best of my knowledge and my son/daughter has my permission to participate in conference activities with the exception of those noted above*. I authorize Benedictine College and/or the Benedictine leadership Conference coordinators to release medical information regarding the above named participant to interested parties including parents and family physician.
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Parent or legal guardian must sign Date
In consideration of my child’s acceptance to the Benedictine Leadership Conference, I, individually and on behalf of my minor child, do hereby release and forever discharge conference organizers, coordinators, Benedictine College and its officers, trustees, employees, contractors and representatives from all liability of any kind for any claim, demand, action, cause of action, damage, judgment, cost or expense which arises out of, occurs during or relates in any manner to my child’s participation in the aforementioned summer conference or any travel incident thereto. I hereby grant permission to the staff of Benedictine College and any other medical provider or surgical consultant deemed advisable by Benedictine College, and any hospital or similar facility, to render to the above-named participant any medical, surgical or other treatment that they deem necessary. I understand that the College will exercise its best efforts to inform me in the event of such treatment. I also understand and acknowledge by my signature below that Benedictine College does not have the medical staff or resources available during summer camps to store or administer prescription or non-prescription medications for my child. I, individually, and on behalf of my child and our respective heirs, successors, personal representatives and assigns hereby release and forever discharge the College and its officers, trustees, employees, contractors and representatives from all liability of any kind for any claim, demand, action, cause of action, damage, judgment, cost or expense which arises out of or relates in any manner to the use, misuse, theft, loss or failure to adequately safeguard my child’s medication at any time.
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Parent or Legal Guardian’s Name (printed) Date
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Signature of Parent or Legal Guardian
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(Phone:) Home (Phone:) Cell