CSI: Cincinnati 2021 - Oct. 17-22

  • This is to be filled out by parents/guardians only.
  • Info needed:  health insurance and physician information; 2 emergency contacts
  • By submitting this form, you are completing several permission/release forms:
    • the BCHS release form
    • the Tau House COVID Waiver and the Tau House Permsission/ Release/ Medical Power of Attorney /  Photo Release form . ( A 'Question Mark' by a field of info indicates that this information will be included on the Tau House forms.)
      Consen terms in the above 2 forms are displayed within the form.
    • Forms for Sites of Service: St. Vincent de Paul, Sweet Cheeks Diaper Bank, Matthew 25:Ministries and Freestore Foodbank
      PLEASE OPEN and read the Sites of Service consent forms.

Student Information

Gender * 🛈
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Class of * 🛈

Medical Information

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Does the student have health/accident insurance? *

INSURANCE INFORMATION: (Both lines MUST be completed.)
A copy of the front and back of the Insurance Card is requested by Tau House. Please scan or even take a photo with your cell phone and upload the photos here.  You can add 2 at one time or upload 2 separate times.  If you experience difficulties, try a smaller file size.

Parent/Guardian Information

Relinquish of Claims against Bishop Chatard HS only

I recognize and acknowledge that there are risks in my child’s/ward’s presence and participation in the school sponsored program identified above. I agree to indemnify Bishop Chatard High School and it harmless, and I hereby waive and relinquish all claims, including any claims arising out of negligence that I may have against Bishop Chatard High School, its officers, agents, employees, representatives or volunteers arising out of any activity my child/ward participates in while attending the program or in connection with transportation to or from the program.
  I agree that my child shall abide by all Bishop Chatard rules and policies. I have reviewed and discussed the rules and policies with my child prior to signing this form. I agree that if my child fails to abide by the rules/policies, or engages in a serious infraction, he or she may be immediately dismissed from the school sponsored program above with no refund, and sent home at my expense. 
  I understand that my child may be photographed, unidentified in group situations; and I hereby grant permission for my child to be photographed & identified for releases to Bishop Chatard and the Bishop Chatard website and/or other promotions
Medical Release
  Our permission is hereby given to the school representative of Bishop Chatard High School to authorize, by his/her signature, whatever medical or surgical treatment may be considered necessary or advisable by the physician or nurse in attendance in the event of an accident or medical emergency involving my student.

Tau House COVID Waiver of Liability, Assumption of Risk and Indemnity - PLEASE READ THOROUGHLY

By filling in this online form, you will be completing the required 'COVID' form for Tau House as stated below. (View their forms in entirety here).
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread mainly from person-to-person contact, and that people can be infected while showing no symptoms and therefore spread the disease. Evidence has shown that COVID-19 can cause serious and potentially life threatening illness and even death. As a result, federal, state, and local governments and federal and state health agencies recommend being vaccinated against the virus, and, if unvaccinated, practicing social distancing and mask wearing.
As we navigate through this unprecedented time as responsibly as we can, Tau House has implemented a number of new safety measures based on guidance from health authorities, such as the Centers for Disease Control and Prevention (CDC) and appropriate government agencies.
We ask that Tau House group leaders inform all individuals who will be participants in your event to follow COVID-19 precautions that include, but are not limited to:
• Vaccination against the virus is strongly recommended, although not required to participate in our program;
• Face masks are recommended but not required for guests on the premises;
• Face masks are still required by many of our partner agencies and must be wore to volunteer sites;
• Masks should cover mouth, nose and chin, (excluding those unable to do so because of a medical condition);
• Self-monitoring for fever and other signs/symptoms of illness;
• Not attending the event: if feeling unwell, awaiting a COVID-19 test result, had close contact with an infected individual, or had close contact with an individual whsuspected of being infected; and
 
Tau House will operate with the following precautions:
• Notice of risk and need to self-monitor for illness will be posted at Tau House entrance;
• Staff will wear masks and wash hands frequently;
• There will be an increased focus on disinfection and sanitation of our facility.

While these precautions are wise, Franciscan Ministries’ Tau House cannot prevent you or your fellow participants from becoming exposed to, contracting, or spreading COVID-19 while participating in the Tau House program. Despite safety measures, it is not possible to prevent against the presence of the disease. Therefore, if you choose to participate in the Tau House program you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19.

ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself. I will take responsibility to be in compliance with state orders and requirements and Tau House precautions while participating in the Tau House program.

WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against Franciscan Ministries’ Tau House and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to participating in the Tau House program. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.

CHOICE OF LAW: I understand and agree that the law of the State of Ohio will apply to this contract.

Tau House Release of Liability -- PLEASE READ THOROUGHLY

By filling in this online form, you will be completing the required 'Applicant Information and Release Liability' form for Tau House as stated below. (View their forms in entirety here).
 
1. I, the lawful parent or guardian of the “student” above, give permission for my child to participate in the activity.  I release from all liability and indemnify Franciscan Ministries, the Franciscan Sisters of the Poor, and their officers, agents, representatives, volunteers and employees, 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”), 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 Franciscan Ministries, the Franciscans Sisters of the Poor, the Archbishop, the Archdiocese, and their officers, agents, representatives, volunteers and employees.
2. I further understand that my/my Child’s participation is purely voluntary and is a privilege and not a right, and that I/my Child, and I on behalf of my Child, elect to participate in spite of the risks.
3. I agree to cooperate/to instruct my child to cooperate with Franciscan Ministries or its agents in charge of the activity.
4. I appoint Franciscan Ministries or its 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 my best interest/the best interest of the Child.
(ii) I understand that the agents of Franciscan Ministries 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 related travel.
6. I agree that Franciscan Ministries or its agents may use my/my child’s portrait or photograph for promotional purposes, website and office functions and use social media/technology to communicate to me/my child regarding ministry related activities.
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 this 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.
CONSENT: * 🛈
Use your mouse or use your finger on a touch screen to enter your electronic signature. Try to write as large as the box allows.
Parent/Guardian Written Signature * 🛈
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