Appendix A:
VOLUNTEER RISK AWARENESS AGREEMENT
I, _______________________________________, will offer my time and services as a volunteer to
________________________________________ (Name of Parish/Institution). I hereby acknowledge and state
that I am not their employee, nor am I eligible for any compensation or benefits provided to an employee. As a
volunteer, I recognize and acknowledge that I am not being compensated in any manner for services rendered. I
further recognize and acknowledge that I am not provided with any form of workers’ compensation or disability
insurance coverage or other similar insurance program. As a participant in this program, I hereby state that I am
aware of and accept the risk inherent in the above program activity.
Liability Coverage: I have been informed that the Diocesan Insurance Program maintains comprehensive
general liability insurance, as well as directors and officers insurance, to protect me as a “Covered Person” for
my negligent actions covered under these policies, only while acting in the scope of my defined
responsibilities, which may result in damage or injury to another person or persons. However, I acknowledge
these policies will not protect me for criminal or intentional acts committed by me. I further understand that
there may be no insurance coverage for allegation of negligence in claims of sexual abuse activity involving a
minor, which would include hiring, retention, and/or supervision of any kind.
Use of Vehicles: I further acknowledge, with regard to any personal vehicle driven by me as a volunteer that in the
event of an accident, there is no coverage afforded to me through the Diocesan Master Insurance Program for
physical damage sustained to any vehicle involved or liability incurred by me while operating my vehicle.
Reimbursement of Medical Expenses: I recognize and acknowledge there is volunteer accident coverage as well
as medical payments coverage available to me in order to compensate me for expenses I incur from deductibles,
co-payments, prescription drugs, or medical services not covered through my own health insurance provider(s) for
any injury I sustain as a result of performing my services. I agree that any medical coverage(s) I have will be
primary and under no circumstance will I seek any contribution from the Parish, or their insurer, for any medical
expenses until all underlying coverage that may or may not apply is exhausted. I acknowledge that the
circumstance and levels of coverage may vary and that the Diocese is under no obligation to continue to maintain
any such coverage for my medical expenses.
Informed Consent to Medical Treatment: In the event of an injury, I hereby give the PARISH full authority to
take whatever action they feel is warranted under the circumstances regarding my health and safety if I am not in a
condition to give informed consent including but not limited to the application of emergency medical procedures,
the admittance to a hospital, or the care of a medical professional at my expense.
Safety: Further, I agree to follow all procedures and safety precautions set forth by the Diocese and the PARISH
in addition to ensuring the protection of minors from sexual misconduct and/or child abuse in order to conform
with the requirements adopted by the United States Conference of Catholic Bishops and Catholic Diocese of
Arlington Policy on the Protection of Children/Young People and Prevention of Sexual Misconduct and/or Child
Abuse.
Photo: Also, I authorize the Diocese of Arlington to use my picture or video recording for educational and/or
marketing purposes. If you wish not to be photographed or filmed you should notify the Office of Youth Ministry
in writing.
I freely execute this Acknowledgement with full knowledge of its content and complete understanding of my
status and rights as a volunteer.
Signature of Participant
Date
Signature of Parent if Participant is less than 18 years old
(Parents must also complete a medical release for all minors)
Date
Signature of Parish/School Volunteer Coordinator
Date
Appendix B:
PARTICIPANT AGREEMENT, RELEASE & ACKNOWLEDGEMENT OF RISK
I, _______________________________________, am a participant in _________________ (Name of
Program/Activity) and hereby acknowledge that this program may involve a variety of activities which may be
both physical and mental in nature. These activities are designed to be within the limits of a person who is in
reasonably good health. The level of participation in all programs and activities is at all times completely up to the
individual. Safety is a high priority in all programs. In addition, each participant must assume the risk that he or
she may suffer an emotional or physical injury and disability.
Liability Coverage: The Parish/School is not furnishing and is not responsible for and assumes no liability in
connection with participation in this activity. The Parish/School is not furnishing and is not responsible for and
assumes no liability of guarantee or assurance of safety of participants and/or elimination of all risks from the
environment. The Parish/School is not furnishing and is not responsible for and assumes no liability for the
safety of personal property during participation in the program. The Parish/School is not furnishing and is not
responsible for and assumes no liability for monitoring and/or control of all the daily personal decisions,
choices, and activities of the individual participants. The Parish/School is not furnishing and is not responsible
for and assumes no liability for assumption of responsibility for the actions of persons who are not volunteers
or employees of the Parish/School or otherwise engaged by the Parish/School, for events that are not part of
the program, or that are beyond the control of the Parish/School and its subcontractors. I voluntarily and
without reservation and on behalf of myself, my heirs, and my estate, hereby indemnify, defend and hold
harmless the PARISH, to include but not limited to, the Diocese of Arlington, The Most Reverend Paul S.
Loverde and his successors in Office, their officers, and employees from any and all liability, loss damages,
costs, or expenses which are sustained, incurred, or required arising out of my actions in the course of the
above program/activity.
Use of Vehicles: I further acknowledge, with regard to any personal vehicle driven by me or which I am a
passenger in, that in the event of an accident, there is no coverage afforded to me through the Diocesan Master
Insurance Program for liability or physical damage sustained to any vehicle involved or liability incurred by me
while operating my vehicle. I acknowledge that if I choose to park at any Diocesan facility, I do so at my own risk.
Reimbursement of Medical Expenses: I recognize and acknowledge there is no volunteer accident coverage nor
is there any medical payments coverage available to me in order to compensate me for expenses I incur from
deductibles, co-payments, prescription drugs, or medical services not covered through my own health insurance
provider(s) for any injury I sustain as a result of performing my services. I agree that any medical coverage(s) I
have will be primary and under no circumstance will I seek any contribution from the Diocese, or their insurer, for
any medical expenses.
Informed Consent to Medical Treatment: In the event of an injury, I hereby give the Diocese of Arlington
and/or its parish(es) full authority to take whatever action they feel is warranted under the circumstances regarding
my health and safety, if I am not in a condition to give informed consent including but not limited to the
application of emergency medical procedures, the admittance to a hospital, or the care of a medical professional at
my expense.
Safety: Further, I agree to follow all procedures and safety precautions set forth by the Diocese and the parish(es)
in addition to ensuring the protection of minors from sexual misconduct and/or child abuse in order to conform
with the requirements adopted by the United States Conference of Catholic Bishops and Catholic Diocese of
Arlington Policy on the Protection of Children/Young People and Prevention of Sexual Misconduct and/or Child
Abuse.
Photo: Also, I authorize the Diocese of Arlington to use my child’s picture or video recording for educational
and/or marketing purposes. Parents/guardians who do not wish their child to be photographed or filmed should
notify the Office of Youth Ministry in writing.
I freely execute this Acknowledgement with full knowledge of its content.
________________________________________________
Signature of Participant
________________________________________________
Signature of Parent if Participant is less than 18 years old
_____________________
Date
_____________________
Date
(Parents must also complete a medical release for all minors)
________________________________________________________________
Signature of Witness
____________________________
Date
Appendix C: FIELD TRIP PERMISSION SLIP
As the parent/legal guardian of ____________________________ permission is hereby given for my child to go on a
Parish trip to: _______________________________ (Destination) on ________________________ (Date). The meeting
time will be ________________ (location) at ______________________ (time) and the pickup time will be
______________________ at __________________. I understand and acknowledge that participation in the activities
involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. I agree to
indemnify the Parish, Youth Ministers, Volunteers, and the Diocese of Arlington for any costs or expenses arising out of
my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees
incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her
participation in the activity. I further give my consent to 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. Also, I authorize the Diocese of Arlington to use my
child’s picture or video recording for educational and/or marketing purposes. Parents/guardians who do not wish their
child to be photographed or filmed should notify the Office of Youth Ministry in writing. I understand that in the event
my child becomes ill with a communicable illness during the trip, I have to make immediate arrangements to retrieve my
child from the trip location.
Date of Birth
Date of last Tetanus Booster
Known allergies including any allergies to medicine (Continue on back of form if needed)
Any other medical problems which should be noted (Continue on back of form if needed)
Name of Parent/Guardian
Address
Phone Home
City/State/Zip
Work
Mobile
Person responsible for charges (if different from above)
Address
Phone Home
City/State/Zip
Work
Mobile
Work
Mobile
Person to notify if parent/guardian is unavailable
Phone Home
Family Physician Phone
Insurance Carrier & Policy Number
Signature of Parent
Date
Signature of Witness
Date
Appendix D:
MEDICAL RELEASE FORM
As the parent/legal guardian of ____________________________ , 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.
Date of Birth
Date of last Tetanus Booster
Known allergies including any allergies to medicine (Continue on back of form if needed)
Any other medical problems which should be noted (Continue on back of form if needed)
Name of Parent/Guardian
Address
City/State/Zip
Phone Home
Work
Mobile
Person responsible for charges (if different from above)
Address
City/State/Zip
Phone Home
Work
Mobile
Work
Mobile
Person to notify if parent/guardian is unavailable
Phone Home
Family Physician Phone
Insurance Carrier & Policy Number
Signature of Parent
Date
Signature of Witness
Date
(please attach a photocopy of BOTH sides of your insurance card here)
APPENDIX E:
FOREIGN TRAVEL RELEASE FORM
For and in consideration of the opportunity to participate in a program of ___________________________involving
travel and study outside the United State of America, I, being of lawful age and under no legal disability, on my own
behalf, as well as on behalf of my heirs, executors, administrators and assigns, do hereby release
_________________________________ (parish name), the Diocese of Arlington, The Most Reverend Paul S.
Loverde and his successors in Office, their officers and agents, from any liability, cause of action, demand for
damages, expenses, compensation and claim on account of or in any way growing out of personal injuries, death or
property damage which may result from my participation in travel or study abroad. I further expressly waive my
right to bring a legal action of any kind for any of the claims released.
I realize that travel and study outside the United States of America involves risk of personal injury, death, or property
damage. I understand that certain risks are inherent in foreign travel and that I fully accept those risks which may
include, but are not limited to, war, quarantine, civil unrest, disobedience or terrorism, public health risks, exposure to
communicable diseases, criminal activity such as assault, kidnapping and theft, adverse weather conditions and natural
disasters such as earthquakes, windstorms and floods, animal attack; insect and animal bites, ill effects of unfamiliar food
and water, incidents related to ground, air or water transportation to include motor vehicle collisions and plane crashes,
injuries or damage to property, and other physical, mental, and emotional injury. I fully assume personal responsibility
for the consequences of the enumerated risks, including the risk of catastrophic injury or death, and all other potential
hazards which may arise in connection with my travel or study abroad, which may result in injury, death, or damage to
property.
I hereby assume full responsibility for learning of, assessing and minimizing all dangers of foreign travel and study. In
signing this release, I have not relied on any statement or representation of ___________________________(parish), its
employees, officers or agents, regarding the nature of any risk, chance or hazard to the safety of my person or property
which may arise in connection with my participation in foreign travel and study. This release specifically includes but is
not limited to a release of__________________________________(parish), the Diocese of Arlington, The Most
Reverend Paul S. Loverde and his successors in Office, their officers and agents for negligent conduct which may result
in personal injury, death or property damage.
I understand that I will be personally and solely responsible for providing any insurance which I deem necessary for my
protection or the protection of my property.
I further state that I have carefully read and understood the foregoing Foreign Travel Release and Waiver, now the
contents thereof, and am signing the same as my own free and voluntary act.
The interpretation and performance of this Agreement shall be construed in accordance with the laws of the
Commonwealth of Virginia and any litigation arising out of this Agreement shall have proper venue in Fairfax County,
Virginia and shall be governed by the laws of the Commonwealth of Virginia.
Participant are strongly encouraged to consult the State Department Consular Information Sheets and Travel Warnings at
http://travel.state.gov/travel_warnings.html and the Centers for Disease Control (CDC) at http://www.cdc.gov with
regard to their destination country(s) prior to signing this Agreement.
Student’s Signature __________________________________ Date________________________
Name (printed) _____________________________________ Destination (s) ________________________
This statement must also be signed by a parent IF the participant is a dependent student (is claimed as a dependent on
either parent’s tax return).
Check one: ____ I am an independent student, or _____ my parent’s signature is provided below.
I hereby give my son/daughter named above permission to participate in this foreign study program. I have read the
statement above and agree that I and my son/daughter understand and assume the risks associated, and that we will hold
______________________________ (parish), the Diocese of Arlington, The Most Reverend Paul S. Loverde and his
successors in Office, their officers and agents harmless, as stated above.
Parent’s Signature_______________________________________ Date___________________________
Parent’s Name (printed) __________________________________
It is also extremely important for students participating in this program to have adequate insurance before departing. This
coverage should also include medical evacuation, repatriation of remains and life insurance. If you are currently included
on your family’s insurance policy, you must make sure that the coverage is valid overseas for the duration of your travel.
Students with an International Student Identity Card (see http://www.istc.org/) receive basic medical/accident insurance
coverage for their travel outside the continental United States, for the period that the ID card is valid. Such coverage may
not be adequate to meet every contingency, so you should check to see what additional protection you might need.
Appendix F: Permission Form for Use of Young Person’s Picture, Voice, Video and/or Full
Name on a Catholic Diocese of Arlington Website or Advertising Material
This letter is to both inform you and request permission for your child’s picture, voice, video
and/or full name to be published on the Catholic Diocese of Arlington and/or an individual
parish’s website or advertising material.
Participant’s images are used on the Internet to promote activities. However, there are potential
dangers associated with posting personally identifiable information on a website because global
access to the Internet means that the Diocese cannot control who may view the website.
Accordingly, the Diocese will not release any information without prior written consent from
you as the parent or legal guardian. Please return this form to your Coordinator of Youth
Ministry to indicate if your child’s image, voice, video, and/or full name may be used on the
Internet or advertising material. This permission will be applicable to any use of full name,
picture, voice, or video taken in the program year in which permission is given and will remain
in effect until the full name, picture, video, or voice is removed from the website or until consent
is withdrawn. As parent or legal guardian, you may withdraw your consent at any time by
sending a written letter, along with a new form, to the Coordinator of Youth Ministry of your
parish. Thank you for your cooperation.
Check one of the following options:
I/We GRANT permission to print, photograph, record and edit as desired the biographical
information, full name, image, likeness, photo, voice, and/or video of this participant on
audio, video, film, slide, or any other electronic and printed formats to be published on
the parish and/or Catholic Diocese of Arlington Internet site or advertising material.
I/We DO NOT GRANT permission to print, photograph, record and edit as desired the
biographical information, full name, image, likeness, photo, voice, and/or video of this
participant on audio, video, film, slide, or any other electronic and printed formats to be
published on the parish and/or Catholic Diocese of Arlington Internet site or advertising
material.
In addition, I agree to release and hold harmless the parish, to include but not limited to the
Diocese of Arlington, the Most Reverend Paul S. Loverde and his successors in Office, their
officers, employees, from any and all claims, demands, actions, complaints, suits or other forms
of liability that shall arise out of or by reason of, or be caused by the use of my child’s picture,
voice, video and/or full name on the Internet or in advertising material.
Participant’s Name:___________________ Parish/Organization Name:____________________
Name of Parent/Legal Guardian: (print) _____________________________________________
Signature of Parent/Legal Guardian (sign):______________________________ Date:________