October 26th, 2019 | Please fill out this form and click submit.
Participant Information

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Parent / Guardian Information

Permission Statement

I grant permission to the adult staff/volunteers to give my child non-prescription medications such as cough drops, antacids, ibuprofen (Advil), etc. I grant permission to the adult staff/volunteers to act on my behalf for the minor named above in granting permission for evaluation and treatment of medical problems during the Holy Fire event. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment as deemed necessary, including surgery, x-rays, scans, and anesthesia to be rendered to said minor by a licensed physician, nurse, or medical professional. I hereby authorize St. Philip, the Diocese of Nashville and its agents to utilize my child’s photographic image for the specific purpose of publication of promotional material, Diocese of Nashville websites and official social media accounts. I understand that I will receive no compensation should any photograph of my child be used. Further, I release St. Philip, the Diocese of Nashville, its employees, volunteers, and student leaders from any claims connected with participation of said minor during this retreat. Electronic Signature Agreement: By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or regarding this agreement, constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and PARISH/SCHOOL and the Roman Catholic of Diocese of Nashville. You also represent that you are authorized to enter into this Agreement for all persons on whose behalf you are signing this Agreement and that such persons will be bound by the terms of this Agreement.
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October 26th, 2019
Please fill out this form and click submit.