Southwest Youth Conference
Hosted by St. Pius X Life Teen Youth Ministry 
LIABILITY/MEDICAL RELEASE FORM-ADULT (18 and over)
Teen participants under age of 18 must have formed signed by legal guardian.
Call Hector Clemente at (915)592-2700 or Oscar Arizpe at (915)759-7558

Group Leader/Confirmation Teacher’s Name: ____________________________________________________

Parish: _____________________________  Participants Name: ______________________________________

Age: _____  Birth Date: _____/_____/______   E-mail: ______________________________________________

Address: _____________________________________ City _______________ State _______ Zip ____________

Home Phone# (____)________________________Work Phone# (____)_________________________________

Emergency Contact: _________________________________________ Phone# (____)_____________________

Family Physician:____________________________________________  Phone# (____)______________

Allergies: _________________________________________  Wheel Chair Disabilities? ___ Yes ___ No

Current Medications: ___________________________________________________________________

Medical History: _______________________________________________________________________

EMERGENCY MEDICAL TREATMENT:
In the event of an emergency, I hereby give permission to the Southwest Youth Conference, St. Pius X Life Teen Youth Ministry, St. Pius X Catholic Church, The Diocese of El Paso and Bowie High School, its officers, directors, agents, volunteers and representatives associated with the conference to transport me to a hospital to receive emergency medical or surgical treatment. I give permission for myself to be evaluated, diagnosed, treated, and/or given medication in accordance with standard medical practice by appropriate health care personnel. In the event of an emergency, please contact:

Name: ________________________________________________________________________________

Relationship: ___________________________________________ Telephone # ____________________

Signature: _________________________________________________ Date:_______________________
		(participant or legal guardian) 

I relieve the Southwest Youth Conference, St. Pius X Life Teen Youth Ministry, St. Pius X Catholic Church, The Diocese of El Paso and Bowie High School of all responsibility and consequences that may arise during the conference or as a result of medical treatment. I will not hold the Southwest Youth Conference, St. Pius X Life Teen Youth Ministry, St. Pius X Catholic Church, The Diocese of El Paso and Bowie High School liable in the event of injury.  Further, I agree to accept any and all financial responsibilities as a result of scheduling medical treatment. I agree to abide by all the rules and regulations stated by the Southwest Youth Conference, St. Pius X Life Teen Youth Ministry, St. Pius X Catholic Church, The Diocese of El Paso and Bowie High School. I understand the Southwest Youth Conference, St. Pius X Life Teen Youth Ministry, St. Pius X Catholic Church, The Diocese of El Paso and Bowie High School will not be liable if I fail to cooperate with regulations, and that any infraction of the rules may result in immediate dismissal from the conference at my expense.

Signature: ______________________________________________  Date: ________________________
	           (participant or legal guardian)