| ST. JOSEPH'S CATHOLIC CHURCH | |||||||||
| Youth Ministry Permission Form | |||||||||
| Event: | Date of Event: | ||||||||
| Participant's Name: | |||||||||
| Home Address: | |||||||||
| Home phone #: | Daytime Phone: | ||||||||
| Emergency contact(s): (Provide name, phone number, and address) | |||||||||
| Are there any conditions or allergies, which may affect the participant's involvement in the described | |||||||||
| event above? | |||||||||
| Yes: | No: | If yes, please explain | |||||||
| Is there any physician prescribed or other medication which the participant may be taken during | |||||||||
| the described event above? | |||||||||
| Yes: | No: | If yes, please explain | |||||||
| Health/Medical Insurance Company: | |||||||||
| Phone Number of Insurance Company | |||||||||
| Parental Permission and Liability Release: | |||||||||
| As parent/legal guardian of the participant above, I (we) do hereby give my (our) permission for him or her to participate | |||||||||
| fully in the event described above. I do for myself and for and on behalf of my child (referred to here as "participant" ) do release , forever | |||||||||
| discharge and agree to hold harmless Saint (St.) Joseph's Church, its directors, employees, and agents thereof from any and all liability, claims, | |||||||||
| and 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 or the participant resulting from said participant's involvement in the above described event (including | |||||||||
| transportation between the participant's home, St. Joseph's Church, and the event location). Furthermore, I (we) 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. Further, authorization and permission are hereby given to St. Joseph's Church, its directors, employees, and | |||||||||
| agents thereof to furnish any necessary transportation, food, or lodging for the participant while he or she is involved in the above described | |||||||||
| event. I (we) hereby authorize St. Joseph's Church, its directors, employees, and agents thereof to admit the participant to a doctor, hospital, | |||||||||
| or other licensed health care provider for medical treatment and 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 (we) do hereby assume responsibility for the | |||||||||
| participant's transportation home and any costs related thereto. | |||||||||
| Parent Signature (and witness): | Date: | ||||||||