Parish Basketball
Parental/Guardian Form for a Child under 18

RELEASE AND INDEMNIFICATION AGREEMENT

I, the lawful parent or guardian of
("my child")
on behalf of myself and my child, irrevocably release from all liability to the fullest extent permitted by the law, and hereby agree to indemnify, defend and hold harmless the Roman Catholic Archbishop of Boston, a corporation sole, its officers, agents, representatives, volunteers, chaperones, clergy, religious and employees including any and all parishes and ministries thereof (collectively, "RCAB"), from and against any and all liability, demands, actions, causes of action, claims, judgments, cost and expense, including but not limited to attorneys' fees, known or unknown at this time, arising out of or in any way related to any injury, illness, loss or other damage to person or property incurred: (a) by my child and/or myself while participating in or traveling to or from, or in any way arising out of, the following event or activity: parish basketball played through (enter name of parish and the town/city they are located on line below) ________________________________________________________________________________________
and played in a variety of locations over the course of the 2024-2025 basketball season; and/or (b) by any other person sustaining or alleged to have sustained any injury, illness, loss or expense, including attorneys’ fees, by reason of my child’s or my negligent or wrongful act or omission.

I agree to instruct my child to cooperate with and follow the rules of the event or activity referenced above and any instructions of the RCAB. In the event my child does not cooperate with or follow same I agree that my child shall withdraw from the event or activity referenced above and that I shall, at my sole cost
and expense, arrange for the immediate transportation of my child from the event or activity referenced above to my home, if so requested by RCAB.

MEDICAL AUTHORIZATION

I appoint RCAB or its agents as my lawful attorney-in-fact, to act for me in my name and stead and on my behalf, in any way that I would, in the reasonable and sole judgment of RCAB be expected to act if I were personally present, with respect to any injury, illness or medical emergency occurs during the activity.

I authorize RCAB or its agents to give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child/ward. I understand that RCAB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child/ward.

The release/indemnification/defense provisions above shall apply to any such decision or action.

The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCAB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child/ward’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence.

This power of attorney shall lapse automatically upon completion of the activity listed above that my child/ward is participating in or attending and related activities, and travel if any, and the return of my child/ward to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release and Indemnification Agreement, each of which shall continue in full force and effect.

I understand and agree that RCAB is not and shall not be responsible for assuring that my child/ward takes any medication, prescription or otherwise, which may be indicated for my child/ward. There are no medical conditions, nor any life-threatening allergies to foods or medicines, that would limit my child/ward’s full participation in the activity or require any special precautions except as I list here:

List any current medications and dosage (prescription and/or over the counter) that the RCAB might need to know about should an emergency arise here:

If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCAB.

As evidenced by my signature below, RCAB and Its agents, including but not limited to, may use my child’s portrait, photograph or video for promotional purposes related to the advancement and development of the ministry of the parish, Roman Catholic Church, and the Archdiocese of Boston, and hereby release RCAB and Its Agents from any liability resulting from such use. 
      	I GIVE permission____________________________    
I DO NOT give permission_____________________

By signing below, I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCAB’s agreement to allow my child/ward to participate in this voluntary activity, trip, or event, and as an inducement to the RCAB, to permit such participation, without which it would not do so. I request that my child/ward be allowed to participate in the above referenced activity, trip, or event.

Signature of Parent or Guardian:  	
Date  	

Signature of Child:  	
Date  	

PLEASE PRINT THE FOLLOWING INFORMATION

Name of person signing this form: Name of child:
Date of Birth of child:
Complete Address: City, State, Zip Code: Phone – Work:

Home:

Cell:

#1 Emergency Contact (other than yourself):
Relationship

Phone - Work:
Family Doctor’s Name:
Child’s Health Insurance Provider:
Membership Number:
Home:
Cell: