Blank Permission Slip

Parent/Guardian Permission and Liability Wavier

Description of Activity/Event:

Event Dates	Required*
Type of Event	Required*
ER Phone Numbers:
Destination:
Individual In Charge:		Joe Maggio and Volunteers
Mode of Transportation:

Participant Information:

Participant Name:

Birth Date:

Age

Grade

Parent/Guardian's Name:

Address

Street 1

Street 2

City

State

Zip

Home Phone

Alternate Phone

Cell Phone

E-mail Address

Permission to Participate:

I (Parent/Guardian Name)	Required*
grant permission for my son/daughter (Child's Name)	Required*
to participate in this parish youth ministry event, that requires transportation to a location away from the parish site. This activity will take place under the guidance and directions of Parish employees and/or volunteers from St. Mary Magdalene Catholic Church.
Signature of Parent/Guardian:	Required*
Date:	//

Hold Harmless Agreement:

Message	As parent/legal guardian, i remain legally responsible for any personal actions taken by my son/daughter named above. I agree on behalf of myself, my son/daughter named herein, our heirs, successors, and assigns to hold harmless and defend St. Mary Magdalene Catholic Church, its officers, directors, agents, Life Teen, Inc., and the Diocese of Charleston from any liability for illness, injury or death arising from or in connection with my son's/daughter's attending the above named activity/event.
Signature of Parent/Guardian:	Required*
Date:	//

Permission To Be Photographed:

I give my permission for my child,

to be photographed at this event and understand that the photographs may be used for publicity, etc.
Required*

	Yes
	No

Signature of Parent/Guardian:

Required*

Date:

	1. The use of any tobacco products, alcohol, or illegal drugs is strictly prohibited. 2. Absolutely no immoral activity will be tolerated. 3. Curfew (when applicable) will be observed by all persons. 4. All injuries and illnesses must be reported to the Function Coordinator. 5. All persons must remain with the group that they are assigned to. 6. No abusive language will be tolerated from anyone. Anyone caught breaking these rules will be asked to call their parents to be picked up.

Emergency Contact Information:

Parent/Guardian's Name:

Full Address:

Street 1

Street 2

City

State

Zip

Home Phone:

Cell Phone:

Message

If you are unable to reach me, please contact:

Name:

Phone Number:

Relationship to me or my son/daughter:

Release of Information:

To the best of my knowledge, my child,	Required*
Message	I hereby grant medical personnel permission to release medical information to the Diocesan Director and/or my parish youth minister in the event that my youth becomes ill or injured.
Signature of Parent/Guardian:	Required*
Date	//
Message	is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I give permission to transport my child to a hospital for emergency treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Insurance Information:

Insurance Carrier:
Policy Number:

Medical History:

My son/daughter is under the care of a psychiatric/psychologist.

	Yes
	No

Name:

Phone Number:

Please Explain:

My son/daughter is taking medication and will bring all medication with him/her and it will be clearly labeled. My son/daughter is taking the following medication(s) and directions for taking this medication, including dosage, frequency and storage are:

I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) To be given to my child if necessary.

	Yes
	No

My son/daughter is allergic to the following:

My son/daughter's immunizations are current and up to date

	Yes
	No

My son/daughter has the following limitations:

My son/daughter experiences homesickness, emotional reactions to new situations, sleepwalking, fainting, bedwetting, etc.

	Yes
	No

Please Explain:

Signature of Parent/Guardian:

Required*

Date

Adult Shirt Size:

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