YM Service Project

As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

As parent/legal guardian of the participant names above, I give my permission to participate fully in NATIVITY YOUTH MINISTRY SERVICE PROJECT from FEBRUARY 9, 6:45 AM (Start Date/Time) to FEBRUARY 9, 11:00 AM (End Date/Time). I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above-described event.

I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment when a condition or injury arises that is serious enough that a reasonable person would seek care right away. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.

I will offer my time and services as a volunteer to Nativity YM SERVICE PROJECT (February 9). I hereby acknowledge and state that I am not their employee, nor am I eligible for any compensation or benefits provided to an employee. As a volunteer, I recognize and acknowledge that I am not being compensated in any manner for services rendered. I further recognize and acknowledge that I am not provided with any form of workers’ compensation or disability insurance coverage or other similar insurance program. As a participant in this program, I hereby state that I am aware of and accept the risk inherent in the above program activity. I hereby acknowledge that this program may involve a variety of activities which may be both physical and mental in nature. The level of participation in all programs and activities is at all times completely up to the individual. Safety is a high priority in all programs. In addition, each participant must assume the risk that he or she may suffer an emotional or physical injury and disability.

I have been informed that the Diocesan Insurance Program maintains comprehensive general liability insurance, as well as directors and officers’ insurance, to protect me as a “Covered Person” for my negligent actions covered under these policies, only while acting in the scope of my defined responsibilities, which may result in damage or injury to another person or persons. However, I acknowledge these policies will not protect me for criminal or intentional acts committed by me. I further understand that there may be no insurance coverage for allegation of negligence in claims of sexual abuse activity involving a minor, which would include hiring, retention, and/or supervision of any kind. I voluntarily and without reservation and on behalf of myself, my heirs, and my estate, hereby indemnify, defend, and hold harmless the Diocese of Arlington, The Most Reverend Michael F. Burbidge and his successors in Office, their officers, and employees from any and all liability, loss damages, costs, or expenses which are sustained, incurred, or required arising out of my actions in the course of the above program/activity.

I further acknowledge, with regard to any personal vehicle driven by me as a volunteer that in the event of an accident, there is no coverage afforded to me through the Diocesan Master Insurance Program for physical damage sustained to any vehicle involved or liability incurred by me while operating my vehicle.

I recognize and acknowledge there is volunteer accident coverage as well as medical payments coverage available to me in order to compensate me for expenses I incur from deductibles, co-payments, prescription drugs, or medical services not covered through my own health insurance provider(s) for any injury I sustain as a result of performing my services. I agree that any medical coverage(s) I have will be primary and under no circumstance will I seek any contribution from the Parish, or their insurer, for any medical expenses until all underlying coverage that may or may not apply is exhausted. I acknowledge that the circumstance and levels of coverage may vary and that the Diocese is under no obligation to continue to maintain any such coverage for my medical expenses.

In the event of an injury, I hereby give the PARISH full authority to take whatever action they feel is warranted under the circumstances regarding my health and safety if I am not in a condition to give informed consent including but not limited to the application of emergency medical procedures, the admittance to a hospital, or the care of a medical professional at my expense.

Further, I agree to follow all procedures and safety precautions set forth by the Diocese and the PARISH in addition to ensuring the protection of minors from sexual misconduct and/or child abuse in order to conform with the requirements adopted by the United States Conference of Catholic Bishops and Catholic Diocese of Arlington Policy on the Protection of Children/Young People and Prevention of Sexual Misconduct and/or Child Abuse.

Also, I authorize the Catholic Diocese of Arlington, its parishes, its schools, and/or the Arlington Catholic Herald to use and publish the photographs and/or videography for which I am featured, and/or audio recordings made of my voice. I agree that the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald may use such photographs, video, and/or audio recordings of me with or without my name and for any lawful purpose, including, for example, such purposes as news, publicity, illustration, bulletin, and Web content.