ST. DEMETRIOS CATHEDRAL ASTORIA GOYA WASHINGTON, D.C. TRIP PERMISSION SLIP AND HEALTH FORMS

Transcription

1 ST. DEMETRIOS CATHEDRAL ASTORIA GOYA WASHINGTON, D.C. TRIP PERMISSION SLIP AND HEALTH FORMS Trip Date(s): February 17, 2019 February 20, 2019 Destination: Washington, D.C. Bus will leave at 7:00 a.m. (2/17/19) from St. Catherine s & George Church and return at approximately 8:00 p.m. (2/20/19) Child Name: Child Date of Birth: Parent/Guardian Name: Relation: Home Phone: Cell: Other: Parent/Guardian Name: Relation: Home Phone: Cell: Other: Other Emergency Contact: Relation: Home Phone: Cell: Other: Child Cell Phone: (for use on the trip only): address: Mode of Transportation: Coach Bus Hotel: Cambria Hotel Washington, D.C O Street NW, Washington, D.C (202) Cost: $ per person quintuplet occupancy (pull-out couch)* $ per person quadruple occupancy* $ per person triple occupancy* $ per person - double occupancy* Trip limited to a maximum of 42 youth** * Includes all taxes, gratuities, lodging, transportation, hotel buffet breakfast on February 18-20, lunch February 17 20, dinner February 17-20, and entrance to the Newseum. ** You must be a paid GOYA member. Registration is on a first come, first serve basis. Payment in full, along with all fully executed attached documents, must be submitted in order to be considered for this trip. Payment will be accepted at GOYA night on Tuesday, September 18 and 25, 2018 and October 2, 2018 at the St. Demetrios Gym. PLEASE DO NOT SUBMIT FORMS/PAYMENT TO ST. DEMETRIOS CHURCH OFFICE. Please make check payable to St. Demetrios Astoria Youth. Members from the St. Demetrios Youth Committee and/or GOYA Committee will chaperone the trip. Please any questions to stdastoriayouth@gmail.com.

2 OVERNIGHT TRIP CONSENT FORM AND WAIVER/RELEASE OF LIABILITY THIS FORM CONSISTS OF TWO PAGES. PLEASE READ BOTH PAGES CAREFULLY. Destination: Washington, D.C. Dates: February 17 20, 2019 My child, whose name I have listed below, has my permission to participate in the overnight trip to Washington, D.C.., from February 17 20, 2019 organized by Hellenic Orthodox Community of Astoria, St. Demetrios, Inc., ( ST. DEMETRIOS ). I understand that the overnight trip involves travel to and from another state, overnight hotel stays. I understand that my child s participation in the overnight trip is a privilege, and not a right. I acknowledge that I have spoken with my child about my child s need to comply with the specific rules and requirements established for the overnight trip. I have specifically notified my child that the use or possession of alcohol or controlled substances and/or weapons (hereinafter contraband ) is strictly forbidden at any time during the overnight trip. I also permit any chaperone accompanying my child to search his/her belongings and/or hotel room for any such contraband and to confiscate same. I understand and consent to my child s room being searched at random by one of the adult chaperones to ensure there in no damage to the room. I further understand that the hotel hallways will be monitored by security guards and that after 10:00 p.m., all children s rooms will be sealed. After 10:00 p.m., children will be allowed to exit their room only in case of an emergency and/or only after an adult chaperone has been contacted and is present. I further understand and agree that I am responsible for, and will reimburse St. Demetrios, for any damage to the tour bus and/or hotel room caused by my child. I give St. Demetrios permission to photograph my child during the overnight trip to Washington, D.C. and to use those pictures on the St. Demetrios Youth Facebook page, website, and/or other print or on-line media outlets. I give my child permission to participate in ice skating and/or snow tubing. The undersigned hereby acknowledges that participation in out-of-state field trips may include situations/activities that involve the risk of harm. The undersigned agrees that for the sole consideration of St. Demetrios allowing my child to participate in the overnight trip to Washington, D.C., the undersigned waives liability, holds harmless, releases and forever discharges St. Demetrios, its members, officers, agents, employees and chaperones from any and all demands, rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, resulting from my child s voluntary participation in the overnight trip to Washington, D.C. The undersigned further agrees that I will not sue St. Demetrios, its members, officers, agents, employees, or chaperones for any claim for damages arising or growing out of my child s voluntary participation in the aforementioned overnight trip to Washington, D.C. This Release, Waiver of Liability and Covenant Not to Sue shall remain in effect for the duration of the aforementioned overnight trip, including dates of travel to and from said destination. If any part of this Release, Waiver of Liability and Covenant Not to Sue shall be deemed null and void, this shall not affect the validity of the rest of this document. This Release, Waiver of Liability and Covenant Not to Sue shall be enforced and interpreted under the laws of the State of New York. CAUTION: THIS DOCUMENT CONTAINS PROVISION(S) WAIVING CERTAIN CLAIMS AND RIGHTS. BY SIGNING THIS AGREEMENT, I CONSENT TO THESE PROVISIONS AND UNDERSTAND THEIR IMPLICATIONS. I FURTHER UNDERSTAND THAT I HAVE THE RIGHT TO CONSULT WITH AN ATTORNEY ABOUT THE PROVISIONS IN THIS CONTRACT BEFORE SIGNING. Child s full name (print) Parent/legal guardian name (print) Parent/legal guardian name (sign) Date: Page 1 of 2

3 (PAGE TWO OF TWO) CHILD PLEASE READ CAREFULLY AND SIGN WHERE INDICATED BELOW I understand and acknowledge that St. Demetrios will have no financial or legal responsibility for injuries or damages arising out of my participation in the overnight trip to Washington, D.C. from February 17 20, I understand that my participation in the overnight trip is a privilege, and not a right. I further acknowledge that I have a responsibility to comply the specific rules and requirements established by St. Demetrios for the overnight trip. I understand that between the hours of 10:00 p.m. to 8:00 a.m., I may not leave my room except for an emergency without first contacting one of the adult chaperones and the adult chaperone being present. I understand that my room will be checked by one of the adult chaperones each evening and morning. I understand that I may not leave the group for any reason. I acknowledge that my failure to comply with such rules and requirements may result in discipline, up to and including suspension or expulsion from any further St. Demetrios youth programs, sports teams and future events and possible dismissal from the overnight trip. Child Signature Date of My Signature Page 2 of 2

4 Medical Information and Parent/Legal Guardian Medical Authorization The purpose of this form is to make it possible for parents and/or guardians to authorize the provision of emergency treatment for children who become ill or injured while under group authority, when parents and/or guardians cannot be reached for the purpose of giving consent for such treatment. A completed form is necessary before the trip. We must have this authorization for each child attending the trip. Medical Insurance Information Insurance Company: Policy Number: Group Number: Family Physician: Phone: Has your child had any of the following (check all that apply): Seizure/convulsive disorder Mononucleosis/Hepatitis Asthma Diabetes Kidney Disease Absence of paired organ Concussion (if so how many times? ) Thyroid Disease Gastrointestinal Disease History of fainting due to exercise or other Been in the hospital except for tonsillectomy Undergone surgery Lower back pain Mental/Emotional problems requiring medical care Serious injury/illness Injury of a muscle, bone, joint, ligament or tendon *Note- If your child has ADD/ADHD or any mental health diagnosis requiring medication while he/she is on the overnight trip, be aware that sustained focus and impulse control is needed throughout the trip. If you choose to send medication, you acknowledge that no chaperone will assist your child with the taking of any medication. If you checked yes to any of the above, please provide additional information: Any known allergies? (food allergies, medicine allergies, bee sting etc.) If yes, please list the allergy and any medication and/or steps of action: Is your child currently taking any medications? If yes, please list the medicine, reason for taking, and dosage: No chaperone will assist your child in the self-administration of these medications. Page 1 of 2

5 In case of medical emergency, I hereby authorize any chaperone who is supervising my child during the overnight trip to procure and consent to any medical care, including any examinations, emergency care, diagnostic processes or courses of treatment deemed necessary by any hospital/physician, for my child during the overnight trip. This Form may be presented to the appropriate emergency medical staff at such time emergency medical care is required. Furthermore, I accept full responsibility for all medical expenses and other costs incurred for medical care provided to my child during the overnight trip. In a medical emergency, if I cannot be contacted despite all reasonable attempts to do so at the contact numbers provided, I hereby consent for my child to receive any treatment reasonably accessible. This authorization does not cover major surgery unless medical opinions of two licensed physicians or dentists, concurring in the necessity of such surgery are obtained prior to the performance of such surgery. Parent/Guardian Signature: Date: Page 2 of 2

6 SCHEDULE A A. I would like to share a room with: ***Please note that we reserve the right to make the final determination on room assignments.***