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Mater Dei Catholic High School
PERMISSION TO PARTICIPATE IN OFF CAMPUS ACTIVITY EXCULPATORY RELEASE and IDEMNITY AGREEMENT
-and-
AUTHORIZATION FOR EMERGENCY MEDICAL AND DENTAL TREATMENT PERMISSION
When: Friday, December 9, 2022
Meet Time: 12:25 PM at Fatima Court. Busses will leave at 1:15 PM.
Arrive Time: Approximately 3:45 PM.
Game Time: 4:00 - approximately 7:00 PM.
Return Time: Approximately 9:00 PM. Students must be picked up at MDCHS within 15 minutes of when we return.
Where: Saddleback College - 28000 Marguerite Parkway, Mission Viejo, California 92692
Reminder:
- Lunch will be available for purchase at school prior to getting on the bus. Students will not have time to leave campus to get food and come back before the busses leave
- Pre-Order your lunch before 9:00 am on Friday @ https://cafemdchs.com
- Students should bring money to purchase food at the game.
- All students who sign up to go on the bus must come back on the bus. No exceptions.
PERMISSION
The undersigned parent(s) or legal guardian(s) of
MDCHS Student Name*
Please enter the name of the student attending the event.
First Name Last Name
Student ID#*
Please enter the student's 4-Digit Student ID#
a student at MATER DEI CATHOLIC HIGH SCHOOL (hereafter “MDCHS”), hereby grant(s) permission for him/her to participate in off campus activity as follows:
Off-Campus Activity*
Date of Off-Campus Activity*
Event Coordinator*
Coordinator Email*
and further consent(s) that he/she may be transported to such activity in a private automobile operated by an adult or student volunteer or by public or chartered bus.

IT IS UNDERSTOOD that adult supervision of the off campus activity will be under the direction of MDCHS and its staff, and the mandatory conditions for volunteer student drivers are: a valid California Drivers License; parent permission to operate the automobile to transport other students; the automobile to be driven is in good operating condition; car pool insurance - $250,000/$500,000 bodily injury and $25,000 property damage; and only the correct number of students are to be in the vehicle. This means ONE STUDENT PER SEAT BELT. Transporting students in the back of a pick-up is NOT ALLOWED.

RELEASE & INDEMNITY

In consideration for the above student being permitted to participate in the off campus activity specified above, the undersigned agree(s) to not make or join in a claim or civil suit for injury, death or property damage against an entity affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, their administrators, staff or volunteers participating in the above off campus activity and hereby release(s) all entities affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, and their administrators, staff and volunteers from all actions, claims and demands the undersigned or the student may hereafter have for injury, death or property damage arising out of negligence or strict liability, as consistent with public policy, arising out of participation in the off campus activity specified above.

Further, if a claim or civil suit is made by the student or someone in a representative capacity on behalf of the student for injury, death or property damage, arising out of participation in the off campus activity specified above, the undersigned agree(s) to indemnify and hold harmless all entities affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, their administration, staffs or volunteers, from any and all such claims, suits, damages, including judgments and /or settlements, whether such claims arise out of the negligence of any such entity or affiliated individual, whether an employee, agent or volunteer, and whether such negligence is active or passive and whether individually or in concert with others.

The above named student will ride
Method of Transportation*

AUTHORIZATION

The undersigned as parent(s) or legal guardian(s) of the above named minor student hereby authorize and grant to the supervising or participating adult permission in the event of illness or injury while participating in the off campus activity specified above to consent to the following:

Any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advise of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act.

Said, authorization to include the release of any medical or dental records to the attending physician or dentist for review.

PARENT/GUARDIAN #1
Name*
Prefix First Name Last Name
Email*
Enter Email Confirm Email

Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone*
Work Phone*
Date*
MM slash DD slash YYYY

Signature*
PARENT GUARDIAN #2
Name
Prefix First Name Last Name
Email
Enter Email Confirm Email

Address
Street Address City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone
Work Phone
Date
MM slash DD slash YYYY

Signature
HEALTH INSURANCE
Health Insurance Provider*

Policy Number*

STUDENT INFORMATION
Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY

Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Email*
Enter Email Confirm Email

Food Allergies/Special Dietary Needs*

Please list any special allergies or special dietary needs. To add additional food allergies or special dietary needs please click the + button to the right of the text box. (If none enter NA)
Daily Medication*
Medication Dose Time

Please list any medications your child is taking above along with the dosage and timing. To add additional medications please click the + button to the right of the text box. (If none enter NA)
EMERGENCY CONTACT
Name*
First Name Last Name
Phone Number*
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The above named student will ride

PARENT/GUARDIAN #1

PARENT GUARDIAN #2

HEALTH INSURANCE

STUDENT INFORMATION

EMERGENCY CONTACT