Form 3 of 3

DIOCESE OF GARY ACTIVITY RELEASE FORMS

PAYMENT AND INDEMNITY
HOLD HARMLESS AGREEMENT

I, (parent/guardian)___________________________, hereby agree to assume full responsibility for the

payment of all debts incurred by my child, (name) ___________________________, during his/her visit to:

(event) ____________________________________________________________________and to reimburse the Diocese of Gary

(and any other participating organizations) for any damages suffered by it due to my child’s acts during the trip.

Waiver of Risk

I understand that, despite careful and proper preparation, there is still a risk of injury when participating in any activity.

In consideration for the Diocese of Gary, the Parish, and Office of Youth Ministry, or any other participating organization, permitting my child to participate in the above activity, I agree to indemnify, defend, hold harmless and release the Diocese of Gary, the Parish, and Youth Ministry, or any other participating organization, and their officers, agents, representatives, employees and volunteers, against and from any and all claims, suits, losses, costs, damages, expenses, and liability arising out of any act or omission or other occurrence, whether or not caused by or resulting from this activity, the Catholic Diocese of Gary, Parish, and Youth Ministry, or any other participating organization, their agents, representatives, employees, and volunteers during the course of the activity in which he or she is participating.

Authorization for Medical Care

I authorize the Diocese of Gary (and any other participating organization) to procure, at my expense, any medical care reasonably required for my child during the trip.

In the event of an emergency, please notify (please provide name, address, and phone):

 _______________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

This Payment and Indemnity Hold Harmless Agreement means that the undersigned will not file a lawsuit or make a claim on behalf of said child against any of the entities or individuals above and will pay the costs of defense or damage caused by a claim by or on behalf of the undersigned.

______________                                 _________________________________________

Date                                                         Signature of Parent or Legal Guardian