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* 1. The undersigned parent(s) or legal guardian(s) of

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: St. Paul Senior Center Service Day, 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 MCHS 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 and 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. 

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* 2. Above named student will ride the school provided bus/van:

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* 3. Above named student will ride with his/her parent/legal guardian:

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* 4. Above named student will ride in a vehicle (other than parent/guardian). 
Note: additional release form must be filled out by student and signed by parent/guardian.

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. 

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* 5. Telephone Number of Parent/Guardian:

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* 6. Name of Alternate if the above cannot be contacted:

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* 7. Family Health Insurance Company & Policy #

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* 8. Name of Student:

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* 9. Date of Birth of Student:

Date

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* 10. Please list any food allergies or special dietary needs:

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* 11. Please list any medications/dosage/frequency:

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* 12. Digital Signature of Parent/Guardian (Please sign this agreement by typing your full name below)*

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* 13. Date

Date
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