7th Grade Blaze 2025-26

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Permission Form

Participant Name*

First Last

Date of Birth*

Parent/Guardian Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Primary Phone*

Parent/Guardian Secondary Phone

Parent/Guardian Email*

Signature of Youth Participant*

Date*

Parental Permission and Liability Release*

As parent/legal guardian of the participant named above, I give my permission to participate fully in the Basilica of Saint Mary's BLAZE small group from October 1st, 2025 to May 31st, 2026, at the Basilica School of Saint Mary, 400 Green St, Alexandria, VA 22314. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge 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 parishes and schools 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.

Informed Consent to Medical Treatment:*

I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment when a condition or injury arises that is serious enough that a reasonable person would seek care right away. 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.

Photo, Press, Audio, and Electronic Media Release:

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

Health Information

Primary Health Provider*

Phone Number*

Insurance Company*

Policy Number*

Emergency Contact Name*

First Last

Relationship*

Phone Number*

Known allergies (including any allergies to medicine)*

Any other medical problems which should be noted*

Signature of Parent/Guardian*

Date*

Payment

Participant Cost*

New Participant

Credit Card

Cardholder Name

Card Details

Total