Totus Tuus 2023 (July 10th-15th) Totus Tuus 2023 (July 10th-15th) Name First Last Names of ParticipantsName/Age/Gender Add RemoveNames of ParticipantsName/Age/Gender Add RemoveNames of ParticipantsName/Age/Gender Add RemoveNames of ParticipantsName/Age/Gender Add RemovePrimary Emergency Contact Information Name/Relation Phone Number Secondary Emergency Contact Information Name/Relation Phone Number Relationship to Participant Address of Participant Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insurance Information Insurance Company Plan Number Member ID Group Name Policy Holder HealthFood Allergies (Type and Severity) Dietary Restrictions Mobility or Activity Limitations Any Other Allergies, health or behavior difficulties of which leaders should be aware of? Needs a ride to, from or both. Ride to St. Mary’s Ride from St. Mary’s Ride to and From St. Mary’s Medical Permission Aspirin Acetaminophen Ibuprofen Benadryl Consent Medical Permission: I understand that the Diocese of Davenport and St. Mary’s assumes no responsibility for accidents which may occur in association with the diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reach, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participant as deemed necessary. Permission for Other Medical Matters: In the event it comes to the attention of the Diocesan and/or parish chaperones that my child complains of illness, I grant permission for non-prescription medication (such as Tylenol, lozenges, etc.) to be given to Participant. Release of Liability for Youth and Adults: I understand all reasonable safety precautions will be taken at all times by the St. Mary’s and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Diocese and St. Mary’s, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event. Code of Behavior for Youth and Adults: I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant’s expense with no right of reimbursement or refund for any amount in connection therewith from the Diocese of Davenport or its chaperones/representatives. Photo Release: I herby authorize the Diocese of Davenport and St Mary’s and its agents to utilize photographic and/or video images of me or my child by the Diocese of Davenport. In giving my consent, I herby indemnify and hold harmless the Diocese of Davenport and Totus Tuus and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used..