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Future Lancer Lifting Program Registration Form

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ARCHDIOCESE OF CINCINNATI PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY (rev. 11-2016)

1. I, the lawful parent or guardian of (the “Child”), give permission for my Child to participate in the La Salle 2023 Future Lancer Lifting Program and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes and schools within the Archdiocese (the “Archdiocese”), La Salle High School, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost and expenses, including attorneys’ fees, arising out of any injury or illness incurred by my Child while participating in or traveling to or from the activity and further agree not to bring or prosecute or allow to be brought or prosecuted (including but not limited to prosecution through subrogation) in my name, or on behalf of my Child, any claims, lawsuits or actions against the Archbishop, the Archdiocese, and their officers, agents, representatives, volunteers and employees.

2. I further understand that my Child’s participation is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, elect to participate in spite of the risks.

3. I agree to instruct my Child to cooperate with the Archbishop or his agents in charge of the activity.

4. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel: (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child. (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.

5. This power of attorney shall lapse automatically upon completion of the activity and any related travel.

6. I agree that the Archbishop or his agents may use my Child’s portrait or photograph for promotional purposes, website and office functions and use social media and technology to communicate to my child regarding ministry related activities. (Facebook,texting,ect.)

7. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that the Permission, Release, and Medical Power of Attorney shall be effective and binding upon me, my Child, and my own and my Child’s personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will.

 

COVID-19 Acknowledgement of Risks

We, the undersigned parent(s) and student, acknowledge and agree that, as a student at La Salle High School and as parent(s) of that student, entering in the school or being on the premises, having personal contact with teachers, classmates, and other La Salle High School staff, involves a certain degree of risk, namely of parent(s) and/or student acquiring a communicable disease, including COVID-19, and then potentially passing it on to others, including family members. Due to the highly contagious nature of COVID-19, the characteristics of the virus, and the close proximity of students, teachers, and staff at La Salle High School, there is an elevated risk of student contracting the disease simply by being in the building, on the premises, or at any La Salle High School function. The same is true for parent(s) of a student at La Salle High School.

By signing this acknowledgement, we acknowledge and agree that after carefully considering the risks involved, and having the opportunity to discuss these risks with any healthcare professional(s) of our choosing, we voluntarily and willingly accept those risks and acknowledge that returning to in-person classes and other in-person La Salle High School functions is the choice of each family, including ours. If student or parent(s) who visit La Salle High School have underlying health concerns which may place them at greater risk of contracting any communicable disease, including COVID-19, we acknowledge and agree that we will consult with a health care professional before student or parent(s) return to La Salle High School, attend any La Salle High School function, or visit La Salle High School. Moreover, we acknowledge that while adherence to safety and precautionary measures (e.g., social distancing guidelines, facemasks, handwashing, etc.) may reduce possible exposure to the risk of contracting a communicable disease, the possibility of serious illness and death remains. We do hereby accept and assume sole responsibility for any illness acquired by student or parent(s) while at La Salle High School or any La Salle High School function, including possible infection with COVID-19.

We further acknowledge, understand, and agree that we have obligations to La Salle High School, its faculty, students, and others to take certain precautions and make certain disclosures to prevent the spread of COVID-19. Specifically, we agree that neither student nor parent(s) will come to La Salle High School or attend any La Salle High School function in person, if in the 14 days prior to coming to La Salle High School or any La Salle High School function, student or parent(s) has had any of the following: new cough, shortness of breath, difficulty breathing, fever of 100.4 °F or higher (intermittent or constant), chills, new muscle pains or body aches, headache, sore throat, congestion or runny nose, new loss of taste or smell, or gastrointestinal symptoms like nausea, vomiting, or diarrhea. This does not apply if these symptoms have been affirmatively diagnosed by a healthcare provider as being caused by some non-contagious illness or condition. In such case, we agree to obtain supporting documentation from our healthcare provider and share such documentation with La Salle High School. Additionally, we agree that neither student nor parent(s) will come to La Salle High School or any La Salle High School function if in the last 14 days, student or parent(s) has had prolonged (more than 10 minutes) close contact (within 6 feet) with anyone, including a family member, diagnosed with or suspected of having COVID-19.

* I acknowledge the Archdiocese of Cincinnati Permission, Release and Medical Power of Attorney (rev. 11-16) and COVID-19 I acknowledge the Archdiocese of Cincinnati Permission, Release and Medical Power of Attorney (rev. 11-16) and COVID-19

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Future Lancers Lifting
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