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ARCHDIOCESE OF CINCINNATI
McNICHOLAS HIGH SCHOOL
PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY

1. I, the lawful parent or guardian of                                                       (the "child"), give permission for my child to participate in the activity described on the reverse side and release from all liability and indemnify the Archbishop of Cincinnati ("the Archbishop"), both individually and as trustee for the Archdiocese of Cincinnati, McNicholas High School, and their officers, agents, representatives, volunteers, and employees from all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.

2. I agree to instruct my child to cooperate with the agents of McNicholas High School in charge of the activity.

3a. I appoint the agents of McNicholas High School who are acting as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel:

(i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child.

(ii) I understand that the agents of McNicholas High School will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

3b. This power of attorney shall lapse automatically upon completion of the activity and related travel.

4. I agree that McNicholas High School may use my child's portrait or photograph for promotional purposes and office functions.

I have carefully read this statement, and my signature acknowledges that I fully understand the contend and meaning.

Signature of Parent or Guardian                                                                                        Date ___/___/___

Address                                                                                               City _____________  State ________

Place of Employment _______________________________________________________

Phone _______________(work) _______________ (home)

Emergency Contact _______________________ Phone___________ (work) ___________ (home)

************************************************************************************ Medical Information -- Completed by Parent or Guardian -- Please Print