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Minor Hold Harmless and Release of Claim Form 5.A

- Instructions
  
  For minors to participate in St. Gabriel Church's hurricane disaster relief efforts, a parent/guardian must read and sign the Diocese of Charlotte's Hold Harmless and Release of Claim form.
  Complete and submit the online form below
  OR
  Print, sign, and return a hard copy to Karen Brown at the church office
  Print hard copy here
- Minor Hold Harmless and Release of Claim Form 5.A - Diocese of Charlotte
  
  This form is not accepting responses at this time.
  
  Volunteer Name REQUIRED Please fill out this field. Please enter valid data.
  
  Volunteer Birth Date REQUIRED Please fill out this field. Please enter a date.
  
  Volunteer Sex REQUIRED Male Female Please fill out this field.
  
  Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.
  
  Home Address REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Accident/Hospitalization Policy Name REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  I hereby grant permission for the above named child to participate in the following volunteer project(s) REQUIRED Please fill out this field. Please enter valid data.
  
  The undersigned, on behalf of themselves, their heirs, successors, and assigns, and on behalf of the above named child, their heirs, successors, and assigns, hereby waive and release the Roman Catholic Diocese of Charlotte, its officers, directors, employees, representatives and agents, from any and all claims arising from or in connection with the activity referred to herein, without limitation.
  
  As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor child. I agree on behalf of myself, the above named minor child, our heirs, successors, and assigns, to hold harmless and defend, the Roman Catholic Diocese of Charlotte, its officers, directors, employees,chaperones, representatives and agents, and any other participating entity or institution, its employees and agents, chaperones, or representatives associated with the activities, from any claim arising from or in connection with the above named child participating in the activities, or in connection with any illness or injury (including death) and/or cost of medical treatment in connection therewith, without limitation, and I agree to compensate the supervising entity or institution, its officers, directors and agents, and the Roman Catholic Diocese of Charlotte, its officers, directors, employees, chaperones, representatives and agents associated with the activities for reasonable attorney’s fees and expenses which they may incur in any action brought against them as a result of such injury or damage.
  
  I consent to the method of transportation and the conditions of said event and/or activity.
  
  My child has the following restrictions and/or allergies (Type "none" if none) REQUIRED Please fill out this field. Please enter valid data.
  
  Please attach a detailed reportof said restrictions and/or allergies. I understand and agree that the failure to attach said report shall be conclusive proof, for all matters, that my child is in good healthand I assume all responsibilities for the health of my child.
  
  With the exception of the above, 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.
  
  The above named volunteer is volunteering their time and labor to the above named project(s). As a volunteer, the above named individual is not eligible for any wagesor other benefits of employment, such as workers compensations insurance, and the undersigned fully waives any claim for the same on behalf of said volunteer.
  Photo Release
  I, and on behalf of my family, heirs, and assigns, hereby grant to the Parish/School/Agency and/or The Roman Catholic Diocese of Charlotte herein referred to collectively as the “Diocese”, permission to record on photography film and/or video, whether digital or otherwise, pictures, images and/or reproductions ofmy child(ren)’s participation and/or my families participation in this activity. I agree that any or all of the material photographed may be used, in any form, aspart of any future publications, brochure, social media, internet or other printed materials that the Diocese deems to be an appropriate use, and further that suchuse shall be without payment of fees, royalties, special credit or other compensation. I agree to indemnify and hold harmless the Diocese, its agents,representatives and assigns from any and all claims regarding the use of said material. Furthermore, I hereby waive any and all claims that I may have, or here after acquire, regarding the use of said material by the Diocese, its agents, representatives and assigns. This release shall not expire unless revoked by me in writing.
  
  I give my permission for the above named child, in case of an emergency, to be taken to a physician and/or hospital by either the supervisor in charge or by an adult authorized by the supervisor in charge. I understand that every reasonable effort will be made to contact me. If I cannot be reached, however, I hereby give permission to the physician selected by said adult to hospitalize and secure proper treatment (including surgery) for the above named child. The cost of any medical care or treatment obtained for the benefit of the above named child shall be my expense and not paid by the Roman Catholic Diocese of Charlotte.
  
  SOURCE: DIOCESE of CHARLOTTE Risk Management and Insurance Manual August 2024
  
  PARENT/GUARDIAN SIGNATURE: Type first and last name to sign REQUIRED Please fill out this field. Please enter valid data.
  
  TODAY'S DATE REQUIRED Please fill out this field. Please enter a date.
  
  Submit
  
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St. Gabriel Catholic Church

Charlotte, NC

Minor Hold Harmless and Release of Claim Form 5.A

Instructions

Minor Hold Harmless and Release of Claim Form 5.A - Diocese of Charlotte

Photo Release