Holy Spirit Boxing Club

(If none, please put N/A.)

As parent/legal guardian of the participants named above, I give my permission for those individuals to participate fully in the Boxing Club. I agree to indemnify and hereby release the Most Rev. Michael F. Burbidge, Bishop 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 parties 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.

By inputting my name, I acknowledge agreement of the permission and liability release shown above.

I request that in my absence the above named minor be admitted to any hospital or medical facility for diagnosis and treatment. 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.

By inputting my name, I acknowledge agreement of the Informed Consent to Medical Treatment shown above.

I authorize the Catholic Diocese of Arlington, its parishes, school 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.

By inputting my name, I acknowledge agreement of the Photo, Press, Audio, and Electronic Media Release shown above.

If paying by check, please make the check out to "Holy Spirit Church"