Informed Consent to Medical Treatment: I request that in my absence the above-named minors be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo, Press, Audio, and Electronic Media Release: I authorize the Arlington Diocese and Holy Family Catholic Church to use my child´s picture or video for educational and/or marketing purposes. Should the need arise; I give permission for my child/children to receive emergency medical care while participating in Holy Family Church Religious Education program.

Parental Permission and Liability Release: As parent/legal guardian of the participant names above, I give my permission to participate fully All Summer Friendship Activities from June 23rd to August 11th. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.

Consentimiento informado para tratamiento médico: Solicito que en mi ausencia, se admita al menor previamente citado, a cualquier hospital o establecimiento médico para diagnóstico y tratamiento. Solicito y autorizo los médicos, a los dentistas y otro personal debidamente acreditado, Doctores en Medicina o Doctores en Odontología u otros técnicos y personal de enfermería acreditados, para que realicen cualquier procedimiento de diagnóstico, tratamiento o procedimiento quirúrgico y tratamiento de rayos X, que el menor previamente citado necesite. No se me ha dado ninguna garantía con respecto a los resultados del examen o del tratamiento. Autorizo al hospital o al establecimiento médico que disponga de cualquier espécimen o tejido tomado del menor previamente citado. Asumo plena responsabilidad por todos los costos de ese tratamiento. Además, si fuera necesario que el participante regresara a casa por razones médicas, disciplinarias o de cualquier otra índole, asumo por medio del presente instrumento toda responsabilidad para el transporte del participante a casa y los costos relacionados con dicho transporte.

Foto, comunicado de prensa, audio y medios electrónicos: Autorizo a la Diócesis de Arlington y a La Iglesia de La Sagrada Familia para utilizar la foto o video de mi hijo para fines educacionales/comerciales. Si fuera necesario, Doy permiso que mi hijo/hijos reciban atención médica de emergencia mientras participan en el programa de catequesis de la Iglesia de La Sagrada Familia.

'23 Summer Friendship (Form 1 - Student Info and Medical History)