adult liability medical form

1. 1
St. Thomas the Apostle R.C. Church Corporation
2015 Catholic Kids Camp
Liability/Medical Release Form
Counselors Over 18/ Adult Volunteers
Participant Name: ______________________________________ Birth Date: ______/______/______
Address: ____________________________________________________________________________
City: ________________________________________________ State: ___________ Zip: __________
Phone: __________________________ E-mail: ____________________________________________
Parish: ______________________________________________________________________________
Family Physician: __________________________________ Phone: ____________________
Allergies or Medical Conditions (please be specific): ______________________________
______________________________________________________________________________
______________________________________________________________________________
Current Medications: __________________________________________________________
Relevant Medical History (please be specific): ____________________________________
______________________________________________________________________________
______________________________________________________________________________
Medical Insurance Provider: __________________________ Insurance #: ______________
In case of emergency, please contact:
Name: ___________________________________ Relation to Participant: ______________
Phone #1: _____________________________ Phone #2: _____________________________
Name: ___________________________________ Relation to Participant: ______________
Phone #1: _____________________________ Phone #2: _____________________________

2. 2
I, ________________________________________, agree to participate in the Catholic Kids Camp
Program to be held at St. Thomas the Apostle R.C. Church (“St. Thomas”) in Norwalk, CT. If
needed for health reasons, I give permission to be evaluated, diagnosed, treated,
transported, and/or given medication in accordance with standard medical practice by
licensed medical personnel. I relieve St. Thomas and the Diocese of Bridgeport or any of its
employees, representatives, or agents of all responsibility and consequences that may arise
as a result of this treatment. I will not hold St. Thomas or the Diocese of Bridgeport liable in
the event of injury. I understand and agree that if I suffer any form of allergic reaction,
emergency medical responders will be called. Further, I agree to accept any and all financial
responsibility as a result of receiving such medical treatment.
I agree to abide by all rules and regulations stated by Camp Staff of St. Thomas. I understand
that St. Thomas and the Diocese of Bridgeport or any of its agents will not be held liable if I
fail to comply with all rules regulations, and that any infraction of the rules or regulations may
result in immediate dismissal from the program at my expense.
I hereby attest and represent that I have complied with all requirements of the Diocese of
Bridgeport’s Safe Environment Program and have provided copies of all pertinent
documentation related thereto to St. Thomas. I agree to continue to follow all policies and
procedures identified and outlined by the Diocese of Bridgeport related thereto.
Signature of Participant: ______________________________________________________________
Printed Name of Participant: __________________________________________________________
Date: _________________________