BOLD 2021 Catholic Heart Workcamp Liability Form St. James Church Dover, Delaware June 27-July 2, 2021 - BOLD Youth Ministry
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BOLD 2021 Catholic Heart Workcamp Liability Form
St. James Church
Dover, Delaware June 27-July 2, 2021
I request that I [my son/daughter] participate in the BOLD trip to Catholic Heart Work Camp in Dover, DE.
For value received, I agree [on behalf of myself, my child’s other parent if known or living (name of parent)
____________________ and my child] to indemnify Fiat Ventures LLC t/a Fiat Ministries or BOLD Youth Ministry,
and Catholic Ministry Partners, Inc. t/a Fiat Ventures or BOLD Youth Ministry (together, “Fiat Ventures”), the
parishes of St. Elizabeth of Hungary (Wyckoff, NJ), St. David the King (Princeton Junction, NJ), Our Lady of
Peace (New Providence, NJ), St. Anne (Fair Lawn, NJ), St. Isaac Jogues (Marlton, NJ), St. John Neumann (Mount
Laurel, NJ), St. James (Basking Ridge, NJ), St. Joseph (East Rutherford, NJ), St. Luke (Ho-Ho-Kus, NJ), St. Gregory
the Great (Hamilton Square, NJ), Immaculate Heart of Mary (Wayne, NJ), Immaculate Heart of Mary (Scotch
Plains, NJ), Holy Trinity (Bridgewater), St. Ann (Raritan), St. Joseph (Raritan), the Roman Catholic Archdiocese
of Newark, the Diocese of Paterson, the Diocese of Trenton, the Diocese of Metuchen, their representatives,
employees, agents and assigns (including staff, chaperones, volunteers and adult supervisors) (collectively,
“Camp Sponsors”) in any action or demand arising out of my [child’s] actions, including reimbursement for
reasonable attorney’s fees and expenses arising in connection with such action or demand.
I acknowledge the contagious nature of COVID-19, that the CDC and many other public health authorities
still recommend practicing social distancing, that there are risks of infection by participating in a camp
such as Catholic Heart Work Camp, and that these risks extend to my child and any other person who comes
in contact with my child. I further acknowledge that the Camp Sponsors cannot guarantee that my child
will not become infected with COVID-19, or that anyone else who comes in contact with my child will not
become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by
COVID-19 may result from the actions, omissions, negligence, or gross negligence of the Camp Sponsors,
other campers, or their families. I acknowledge that the measures being put in place by the Camp Sponsors
– which Camp Sponsors have communicated I should not expect to be strictly followed at all times – are
reasonable.
I agree on behalf of myself, my child, and any other parent/guardian, to comply with all COVID-19 Protocols
communicated. I agree on behalf of myself, my child, and any other parent/guardian, to inform the Camp
Sponsors if COVID-19 symptoms or diagnosis is experienced by my child, anyone in his/her household, or
anyone with whom my child has had close contact during the camp week or within 14 days thereafter. In
the event that my child, anyone in his/her household, or anyone with whom my child has had close contact
experiences COVID-19 symptoms or diagnosis during this time frame I hereby authorize Camp Sponsors to
disclose such information to other campers and their parents/guardians without regard to the protections
afforded under the Health Insurance Portability and Accountability Act (HIPPA) or any other similar law.
For value received, I agree on behalf of myself, my child, any other parent/guardian, and any other member
of our household, to release and hold harmless the Camp Sponsors from any and all liability, claims, causes
of action, demands, damages, costs, expenses and compensation of any nature whatsoever arising out of or
related to the Catholic Heart Work Camp trip, and regardless of whether related to COVID-19 or any other
illness, to the fullest extent allowed by law, including for liability for bodily injury or death to any person,
regardless of whether caused by the acts, omissions, negligence or gross negligence of Camp Sponsors.
I acknowledge that the BOLD trip to Catholic Heart Work Camp in Dover, DE may entail games and oppor-
tunities for my child to participate in physical and recreational activities. The physical work associated with
a mission trip includes the risks of serious injury or death inherent in repair work, working with power
tools, working from a height, etc. I acknowledge that there are inherent risks in these activities. I specifically waive any and all claims of any nature I may have against the Camp Sponsors relating to or arising out of the above-described activities including claims that may be derived from any accident or injury I [my son/ daughter] may sustain en route to, during, and/or returning from the activity. MEDICAL: I hereby warrant that to the best of my knowledge, I am [my son/daughter is] in good health, and I assume all responsibility for my [my son/daughter’s] health. I understand that Trip Sponsors are NOT permitted to dispense medication without permission. Should emergency medical treatment be necessary and I am unable to be contacted immediately, I authorize the delegated agents of the Trip Sponsors to act on my behalf and approve appropriate treatment. I consent to [my son/daughter] being transported by the Trip Sponsors including chaperones, Bus compa- nies or other parents in compliance with the safe environment policies of the Trip Sponsors. I consent to photographs, video or other media where I am [my son/daughter is] portrayed to be used in connection with this event or for promotional purposes by the Trip Sponsors, including by internet or print publication, although I [my son/daughter] shall not be identified in any publication without prior approval. Teen Printed Name_________________________________________________________________________________ Parent/Guardian Signature _____________________________________________Date______________________ Parent/Guardian Printed Name ____________________________________________________________________
CATHOLIC HEART WORKCAMP L.L.C MEDICAL-RELEASE OF ALL CLAIMS
In consideration for being accepted by Catholic HEART Workcamp
Church: __________________ Contact Leader: _____________________
L.L.C., a Florida limited liability company, I (we) being 21 years of age
or older, do for myself (ourselves) and for and on behalf of my (our)
Participant Name: ______________________________________________ child-participant (if said child is not 21 years of age or older) do hereby
release, forever discharge and agree to forever hold harmless Catholic
Male___ Female___ Age: ______ DOB: ____________________________ HEART Workcamps and its managers, members, directors, officers,
Parent’s/Guardian’s Name: ______________________________________ employees and agents thereof, from any and all liability, claims, demands
for personal injury, sickness, death, as well as property damage and
Home Address: _________________________________________________ expenses of any nature whatsoever, including, but not limited to, bacterial
City: __________________ State: ____________________ Zip: _________ and viral diseases such as COVID-19 and any other infectious diseases,
which may be incurred by the undersigned or the child participant
Home Phone: ________________________Cell Phone: ________________ resulting from said child's participation in the above-described workcamp,
(including travel between the child's home and the camp, free day
Emergency Contact: ________________________Phone: ______________
activities, excursions from the camp and anytime spent at the camp).
Physician Name: ___________________________Phone: ______________ Furthermore, I (we) (and on behalf of our child-participant if under the
age of 21 years) hereby assume all risk of said personal injury, sickness,
HEALTH STATUS (Confidential information please list any health problems death, damage and expenses as a result of participation as above set forth.
you may have examples: asthma, allergies, back trouble, diabetes, seizures, Further, authorization and permission are hereby given to said
mental disorders or illnesses)
organization to furnish any necessary transportation, food, lodging for and
_______________________________________________________________
to assign work projects to this participant. The undersigned further agree
_______________________________________________________________
to hold harmless and indemnify Catholic HEART Workcamp and
MEDICATIONION associated social agencies and day care centers and their directors,
officers, employees and agents, for any loss, claim, liability, damage,
Please list all medications (including over the counter and prescription) taken including property damage or injury whatsoever incurred by child-
routinely. Bring enough medication to last the entire time at camp. Keep participant as a result of the negligent, willful or intentional acts of said
medications in original bottle that identifies the physician, the name of the participant, including reasonable attorney’s fees and other expenses
drug, the dosage and frequency of administration. Keep all over the counter incurred attendant thereto.
medications in original packaging.
Please list all medication that the participant is taking: If the participant has not attained the age of 21 years:
Medication #1_______________Dosage__________Reason______________ I (we) am (are) the parent(s) or legal guardian(s) of this participant, and
Medication #2_______________Dosage__________Reason______________ hereby grant my (our) permission for him (her) to participate fully in said
workcamp, and hereby give my (our) permission to take said participant
Medication #3_______________Dosage__________Reason______________ to a doctor or hospital and hereby authorize medical treatment, including,
but not limited to emergency surgery or medical treatment, and assume
Date of your last Tetanus Booster: _________________________________ the responsibility of all medical bills. I give permission for my child to be
Health Insurance Provider: ______________________________________ transported in privately owned vehicles or in public transportation and for
the release of medical records to an attending physician in case of illness.
Policy Number: _________________________________________________ Further, should it be necessary for the participant to return home due to
Group Number: ________________________________________________ disciplinary action, for medical reasons or otherwise,
Name of Insured: _______________________________________________ I (we) hereby assume and indemnify Catholic HEART Workcamp,
Relationship to Participant: ______________________________________ L.L.C. for all transportation costs. I (we) am aware of no physical, mental
or emotional problems, which would limit participation in or work
performance during the workcamps. I (we) am (are) fully aware of the
(Attach a copy of your insurance card)
nature of the work to be undertaken during the Catholic HEART
Participant Name: ______________________________________________ Workcamp.
Participant Signature: ____________________________________________
The Catholic HEART Workcamp will employ reputable staff members
and take reasonable precautions to safeguard the workcamp participants
Custodial Parent Name: __________________________________________ during the week of workcamp. However, neither the Catholic HEART
Workcamp L.L.C., associated social agencies, nor the school acting as
Custodial Parent Signature: ________________________________________ “home base” will be liable for loss or damage to property of participants
(if under 21 years of age)
prior to, during or following the workcamp due to theft, fire, accident or
any other cause beyond its control.
MEDIA/PHOTO WAIVER
I hereby authorize and give my full consent to Catholic HEART
Workcamp L.L.C. to copyright and or publish any and all photographs,
video or audio in which I/my child will appear in while attending Catholic
HEART Workcamp. I further agree that Catholic HEART Workcamp
may transfer these photographs, video or audio for use on the Catholic
HEART Workcamp website and all promotional material.
Contact Leaders: Please bring this original, plus 2 copies to camp.CATHOLIC HEART WORKCAMP L.L.C. CODE OF BEHAVIOR
(Must be signed by all participants)
As a CHWC participant I will:
• Represent the Catholic Christian community though my language, dress and behavior.
• Respect the rights and property of others.
• Respect CHWC staff and adult leaders, even if these leaders are not from my parish.
• Remove my hat, refrain from eating, drinking, and private discussions during Mass.
• Participate in all planned activities, group sessions and work projects.
• Read over the school, safety and worksite requirements in the youth or adult pre-trip planning booklet and will
abide by them.
• Read over the rules for cell phone usage in the pre-trip planning booklet and will abide by them.
• Respect the privacy of my fellow campers and not go into any other sleeping quarters (guys or girls) that are
not assigned to my group.
• Adhere to the stated curfew (10:30pm prepare for bed and 11:00pm lights out).
• Be responsible for assisting our parish group with snacks and help keep snack area clean.
• Not possess any alcohol, marijuana, non-prescription drugs, electronic cigarettes, JUUL devices, fireworks,
weapons or knives (including pocket knives).
• Not leave the school grounds without adult supervision.
• Not swim in any man-made or natural body of water without permission and supervision by my group leader.
No swimming anywhere is allowed unless approved in writing by the camp director.
• Build new relationships with my team members, resident, agency leaders, others in the community and
children I encounter during this service week.
• Read over the policy on Sexual Harassment / Misconduct.
• Refrain from inappropriate touching and verbal harassment.
• Not engage in any form of sexual activities or sexual harassment.
• Not take part in any form of bullying which includes (one or more students seeking to have power over another
student through the use of verbal, physical or emotional harassment, intimidation or isolation).
If any of the above are violated, CHWC has the right to send a camper home at his/her expense.
I have read, understand and agree to follow the Code of Behavior outlined above. I will also encourage other
group members to live by these rules. We need the cooperation of young adult leaders and adult chaperones to
assist CHWC in making this service week successful. We need your support to help us enforce camp guidelines.
Participant Name: ______________________________________________
Participant Signature: ___________________________________________
Custodial Parent Name: __________________________________________
Custodial Parent Signature: _______________________________________
(if under 21 years of age)
Please return to your Workcamp Contact Leader.
Contact Leaders: Please bring to camp.Diocese of Metuchen
Teen Permission Slip
Activity: _________________________________ Location: _____________________ Date:___________
PLEASE PRINT CLEARLY
Parish Town: ______________________________ Parish Name: ____________________________________
First Name: _______________________________ Last Name: ______________________________________
Home Address: ____________________________ City: ___________________ State: _____ Zip: _________
Phone: ___________________________________ E-mail: _________________________________________
DOB: ________ Age: ___Sex: M____ F___ Grade___ School: _____________________________________
Mode of Transportation: _____________________________________________________________________
Departure Time: ____________________________ Return Time: ____________________________________
Parent/Guardian Name: ______________________ Home Phone: ____________________________________
Parent/Guardian Work Phone: _________________ Cell Phone: ______________________________________
Emergency Contact: _________________________ Best Phone to be reached during activity: ______________
Health Insurance Company: __________________ Policy & Group Number: ___________________________
Family Physician: __________________________ Phone: _________________________________________
Medical Conditions to be aware of: (Circle) Seizures, Asthma, Migraines, and Diabetic Other: ______________
__________________________________________________________________________________________
Allergies: Peanut, Latex, Dyes, Other: __________ Medication Allergies: ______________________________
List all current medications and reason: _________________________________________________________
__________________________________________________________________________________________
List Dietary Restrictions: _____________________________________________________________________
Are immunizations up to date? Yes No Date last tetanus immunization: ______________________
Parent /Legal Guardian’s Signature: ___________________________________ Date:_____________
Make checks payable to ______________________________. Do not send cash in the mail. Registration will
not be accepted without a completed registration form and payment! Notary required only if out of state
activity.
For additional information contact: _____________________________________________________________
Parish Youth Minister: __________________ Youth Minister Cell During Activity: ______________________
For International Travel Only:
Exact Passport Name: _______________________________________________________________________
Date Issued: ______________ Passport Number: ______________________________ Expiration: __________
Attention Parents or Guardians - Please sign both sidesDiocese of Metuchen
Teen Permission Slip
Parent/Guardian: Please read carefully and sign below.
I/we consent to my child, ____________________________________________ (“my child”), participating in the above
described activity and consent to the mode of transportation as indicated. I/we specifically waive and release any and all
claims of any nature which I/we may have now or in the future against the above named parish and/or school, the Diocese
of Metuchen, their representatives, employees, agents and assigns (including, but not limited to, staff and adult
supervisors) arising out of, related to, or connected in any way with the above described activity including, but not limited
to, claims that may be derived from any accident or injury sustained by my child or damages or loss to property in route
to, during, and/or returning from the activity.
AUTHORIZATION FOR MEDICAL TREATMENT
Should emergency medical treatment be necessary and I/we cannot be reached immediately, I/we authorize the delegated
agents of the above-named parish to consent to medical or surgical treatment of an emergent or non-emergent nature,
including in-patient or out-patient hospitalization, to be rendered to my child under the general or special supervision and
advice of a physician, surgeon or dentist. Such consent may include, but it not limited to, medical or surgical diagnosis or
treatment, diagnostic tests, blood tests, x-rays, transfusions, intravenous treatments, administration of medication or
anesthetics, and any related procedures that may be deemed advisable or necessary. It is understood that this
authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to
provide authority and power to the delegated agents of the above-named parish to give specific consent to any and all such
diagnosis, treatment, or hospital care which the aforementioned physician, surgeon or dentist, in the exercise of his/her
best judgment, may deem advisable. I/we understand that I/we assume all financial responsibility for the delivery of such
care at the time that such care is provided by the agency, hospital, or facility. I/we further understand that Diocesan and/or
parish representatives are NOT permitted to dispense medication–unless parents previously discussed a child’s need for a
specific mediation also noted on this form. In the event that my child requires medication during the above described
activity, I/we understand that my child must be trained to self-administer medication or have a parent in attendance to
administer medication.
PHOTO RELEASE
I/we hereby grant to the Diocese of Metuchen and its parishes, schools and assigns, the irrevocable and unrestricted right
to use, reproduce and publish photograph(s) or video(s) of my child, including their image and likeness for diocesan,
parish or school publications, advertising, or website(s), or any other purpose and in any manner and medium; to alter the
same without restriction; and to copyright the same. I/we hereby release The Diocese of Metuchen and its trustees,
officers, employees, agents, legal representatives, and assigns from any and all claims, actions, and liability of whatever
nature and relating to the use of said photograph(s) and/or video(s).
DISCIPLINE / TRANSPORTATION OR DAMAGE COSTS
I/we agree that I/we have read and fully understand the Office of Youth & Adult Ministry’s Policies and Rules of Conduct
(see page 3) and I/we agree to adhere to them. I/we agree to respect the rights and property of others and further
understand that vandalism, stealing or insubordination will not be tolerated. I/we assume all responsibility for any and all
financial obligations that result from any such behavior or the violation of the Policies and Rules of Conduct. Should it be
necessary for my child to return home due to medical reasons, disciplinary actions or otherwise, I/we assume all
responsibility and transportation costs.
Parent/Guardian Name (Print): _____________________________________________ Date: _____________________
Signature of Parent/Guardian: _________________________________ Phone: _________________________________
Address: __________________________________________________________________________________________
City: __________________________________________________ State: _________ Zip Code: ________________
During the hours of this trip/activity I can be reached at (phone/cell phone number) _______________________________
FOR OUT OF STATE ACTIVITY ONLY:
In witness thereof, the undersigned, intending to be legally bound hereby sets their hand and seal the date written below.
Notary Signature (REQUIRED):________________________________________Date:_____________________Diocese of Metuchen
Teen Permission Slip
Youth Participants will
Show Christian consideration, sensitivity and respect to everyone and to the property around them through language, dress
and behavior
Attend all scheduled activities, arriving promptly and staying for the entire event
Refrain from inappropriate touching and verbal harassment
Respect other persons and/or property
Adhere to chaperones directions
Be aware of noise levels in lobbies, hallways and sleeping areas (if applicable), especially later in the evening
Report problems of any kind to a trusted adult
Youth Participants will not
Possess weapons of any kind
Purchase, possess, consume or distribute alcohol or illegal drugs
Engage in any form of sexual activity or peer sexual harassment or verbal harassment
Purchase, download, possess, view or distribute pornography
Visit or gather in hotel rooms with the opposite gender
Act in any manner that could result in injury or property damage
Youth participants will be aware of what are and are not appropriate behaviors in terms of relationships between adults and youth,
with their peers. The following behaviors are generally considered appropriate at an event
Handshakes, high-fives and hand slapping side hugs, shoulder to shoulder or "temple" hugs
Praise for a job well done (not regarding physical attributes)
Arms around shoulders
Holding hands while walking with younger minors
Sitting beside young minors
Kneeling or bending down for hugs with younger minors
Holding hands during prayer
Pats on the head (when culturally appropriate)
Touching hands, faces (usually in context of a blessing), shoulders and arms of minors, arms around shoulders
The following behaviors are generally considered inappropriate at an event
Kisses on the mouth
Inappropriate or lengthy embraces
Touching knees or legs of other participants
Wrestling with others
Being in or on a bed with an adult
Holding anyone on the lap who is capable of sitting on their own
Any type of massage given by adult to minor
Any form of unwanted affection or peer sexual harassment
Piggyback rides
Any type of massage given by minor to adult or another minor
Touching bottom, chests or genital areas
Compliments or put downs that relate to physique or body development
Going to an isolated area away from the group, or being taken to an isolated area by an adult or peer
Showing affection in isolated areas of a facility such as bedrooms, restrooms, bathrooms, closets, staff-only areas or other
private rooms
Youth and parents understand that failure to agree to and abide by the Diocesan Youth Code of Conduct will bar youth from
participation in any diocesan/parish sponsored youth event.
Youth Participant Sanctions for Non-Compliance
Group leaders, chaperones and/or parents bear the responsibility for sharing this information with youth participants. Failure to do so
does not excuse any inappropriate behavior on the part of youth participants nor does it affect the Diocese of Metuchen’s ability to
levy sanctions. If a young person violates the Diocesan Code of Conduct, any or all the following sanctions may be implemented:
1. Reporting of misconduct to local authorities, if the violation in any way violates local ordinance or laws.
2. Dismissal of the youth from the diocesan event or program by requesting that the group leader remove the youth from the
event (whereby it would become the responsibility of the group leader/chaperone/parent to ensure timely, accompanied, and
safe transportation home).You can also read
