After-School Application

1. Permission to Participate

The above-named Parent of the Minor has entrusted the Minor into the care of St. Vincent de Paul (SVDP) while the Minor participates in programs, activities, events, transportation or services sponsored by SVDP. By signing this form, the Parent: 1) grants permission for the Minor to participate in the youth development program of SVDP; 2) authorizes the staff of SVDP to seek medical treatment for the Minor in emergency situations; and 3) agrees to waive any right, cause of action or legal remedy against SVDP, its staff, volunteers, officers, or Board of Directors, arising out of the Minor’s participation in the youth development program of SVDP.

2. Medical Treatment of the Minor

The Parent does hereby authorize SVDP consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under, the general or special supervision of any physician and surgeon licensed under the laws of the State in which medical care is being sought and on the medical staff of any hospital; and/or consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment to be rendered to the Minor by any dentist licensed under the laws of the State in which dental care is being sought. It is understood that this authorization is given in advance of any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care being required, but is given to provide authority and power on the part of SVDP to give specific consent to any and all such examination, anesthetic, diagnosis, treatment, SVDP and hospital care which the aforementioned surgeon, physician, and/or dentist, in the exercise of his or her best judgment, may deem advisable. The Parent hereby authorizes any hospital, which has provided treatment to the Minor to surrender custody of the Minor to a representative of SVDP upon completion of treatment. The Parent hereby agrees to fully pay all costs of medical or dental care incurred for the Minor by SVDP under this authorization.

3. Waiver of Liability

The undersigned Parent hereby waives any and all rights, actions, claims or remedies which the Parent may have against SVDP and its staff, volunteers, officers, and Board of Directors, arising out of any injury or damage that may be incurred by the Minor’s participation in any program, activity, event, transportation or services sponsored by SVDP. By affixing his/her signature below, the Parent acknowledges that the Parent has read this Parental Authorization and the Parent agrees to its terms.

4. Termination

These authorizations shall remain effective as long as the Minor participates in the programs, activities, events, transportation, or services of SVDP unless sooner revoked in writing delivered to SVDP.