ST. JOHN THE EVANGELIST CATHOLIC CHURCH
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CAMPTON MISSION ADULT REGISTRATION FORM 2020

Archdiocese of Cincinnati Release and Indemnification and Medical Power of Attorney Agreement:

1. I am the lawful parent or guardian of the child being enrolled on this form. I give permission for my child to participate in the activity described herein, and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.

2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity.

3a. I appoint the Archbishop or his 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 the best interest of the child.

(ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

3b. The powers and authority granted herein may be revoked by me by written notice delivered to the Archbishop or his agents who are then acting or who have previously acted hereunder. Without such written notice, this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. This power of attorney shall lapse automatically at the end of above said time period.

4. I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes and office functions, and hereby release the Archbishop and his agents from any liability resulting from such use.

(Please indicate your understanding and agreement of this information in the field below.)
I have carefully read this statement and my signature acknowledges that I fully understand its content and meaning.

    CAMPTON MISSION ADULT REGISTRATION FORM

    Please be sure to pay the fee (per person) by mailing it, dropping it in the collection basket, or bringing it into the Parish Office by the deadline.

    ​*If you chose to pay online, please follow this link: https://stjohnwc.weshareonline.org/#. You can also find this link on the homepage (the "Donate or Make a Payment" button).
Submit
We Are the Body of Christ
Parish Theme

9080 CINCINNATI-DAYTON RD 
WEST CHESTER, OH 45069-3129 
PARISH OFFICE: (513) 777-6433
  • Home
  • About
    • Contact Us
    • Events
    • Job Openings
    • Pandemic Portal
    • Parish Forms
    • Prayer
  • Organizations
    • Boy Scouts
    • Girl Scouts
    • Knights of Columbus
    • Society of St. Vincent de Paul
    • Worship Commission
  • Ministries
    • Bereavement
    • Healing Touch
    • Justice and Peace
    • Liturgical Ministers
    • Liturgy of the Word With Children
    • Ministry to Returning Catholics
    • Music Ministry
    • Outreach and Support
    • Share-A-Lunch
    • Spirited Seniors
    • Youth Ministry
  • Faith Formation
    • Adult Faith Formation >
      • Bible and Book Studies
      • Missions & Retreats
      • RCIA
      • Small Church Communities
      • Speakers & Workshops
      • Theology on Tap
    • Children's Faith Formation
    • Sacraments >
      • Anointing of the Sick
      • Baptism
      • Confirmation >
        • Confirmation Interviews
      • First Eucharist
      • First Reconciliation
      • Marriage
  • Media
    • Bulletins
    • E-Memo
    • On Eagle's Wings
    • Watch Online