CICM Youth encounter

Date: November 8, 2025

Place: St. Mary's Catholic Church

1603 Edgerton Street, Goldsboro, NC 27530

Time: 9am-3:30pm

ALERT! ONLY BEGIN THE FORM IF THE PARTICIPANT AND ONE OF PARENTS ARE BOTH PRESENT.

Consent & Liability Waiver Important! To be filled out by the Parent/Guardian for youth under 18 years of age and individuals age 18 or older and in high school.

In consideration of the program in which my son/daughter will participate, I, as parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to participate to this activity.

I acknowledge that (parish name)_________________________________________________________________________________________ is providing transportation to and from St. Mary's Catholic Church, Goldsboro, NC to the event.

I acknowledge and assume the risk of this transportation for my child. My child must comply with (parish name) ___________________________ rules and procedures. By granting this permission, I also waive any claims against, and RELEASE AND HOLD HARMLESS AND INDEMNIFY, (parish name) ____________________________________________, the Diocese of Raleigh, any of their religious, employees, volunteers, agents and representatives from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my child’s participation in the program.

Participant: In signing the line below, I certify all the information on the trip form is complete and accurate, I also agree to abide by any/all policies established for this event/activity. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand there will be consequences for my actions, including being removed from the activity and being sent home at my parents/guardian’s expense.

In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.

Image Release Form

(Photography and Image Assignment Waiver, and Release)

I_____________________________________________________________________________________________________, for valuable consideration received, and for being allowed access to Diocesan property, activities, or events, expressly assign to ______________________________________________________________________________ and the Diocese of Raleigh, and to all of their current, former, and future agents and related entities (collectively, “the Diocese”), all rights, title and interest in, and to, the use of my and my child/ward’s image or likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose (“the Property”). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Raleigh.

I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for any purpose whatsoever, and I further waive all rights to any compensation for my and/or my child/ward’s appearance or participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Diocese. Participants’ names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that may be covering the event in which my child(ren)/ward(s) participate(s).

I hereby waive any claims against and release the Diocese, its current, former, and future religious, priests, employees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property.

This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward’s name may be printed with photos/images in various publications, including non-Diocesan publications.

I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release.

I understand that if my child do not wish to be photographed at this event, I must notify the photograher/organizers AND remove myself from photos being taken.

I understand that if I am against the image release form, I have to let the organizers know in writing. Email to: info@missionhurstcicm.org

Parental/Guardian Medical Information & Consent Form

I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical Information & Consent Form if there are any changes to my child’s health.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment.

Medications: I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. [NOTE: Any/all prescription medications must be in original pharmacy container with young person’s name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person’s name on the container.] I release and hold harmless (parish name) ____________________, the Diocese of Raleigh and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering the medication.

Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:

I hereby authorize any staff member to give my child the following non-prescription medications should he or she need them. (Please check appropriate alternatives. Note: Categories and examples of medications are listed, but other brands may be used.) Dosages should not exceed those recommended by the manufacturer.

I declare that I am eighteen years of age or older, and that I have read and understand the terms of this Authorization, Waiver and Release.