Authorization for Student Excursion and Activities
For Co-Cathedral of St. Theresa Parish
The student's parent(s) or Legal Guardian (s) must complete the Authorization. If not completed and signed the student will not be allowed to participate in the activities and excursion described. Fax or phone permission IS NOT acceptable
Please print clearly.
Youth's Name:
Birth Date: - /- / - Sex:
OM
OF
STREET
Parents' or Guardians' Name: - - - - - - - - - - - - - - - - - - - - - - - Home Phone: Work Phone: Cell Phone: - - - - - Name of Physician: Office Address: Medical Insurance Plan: In case of an emergency, check one: o Hospital preference:
Phone:
_ _
Insurance No.: - - - - - - - - - _
o
No preference; closest hospital
Please list illnesses (example: asthma, heart condition, allergies, diabetes, etc.) that your child has and medications he/she is currently taking:
In case of an emergency and parent(s)/guardian cannot be reached, please call:
Emergency contact:
Phone:
_
I1We, the parent(s)/legal guardian, give my/our pennission for the above named youth to participate in the:
Event: Diocesan Youth & Young Adult Rally Date: Saturday, September 26,2009 Time: 9:00am - 9:30pm Place: St. Theresa Parish hall & Maryknoll Community Center I am/We are the parent(s)/guardian(s) of the above named student. By signing below, I/WE: a. b. c,
d.
Give pennission for the above named student to participate in the excursion and activity named above. Give permission for the student named above to travel by private or commercial vehicle. Release Co-Cathedral of St. Theresa parish and its agents and employees from any and all liability to the student for any injury, damage, or loss that occurs because of the student's participation in the excursion and activity, unless the injury, damage or loss is caused by gross negligence or willful misconduct of the Parish or its agents and employees; and; In the event of illness or injury to the student, consent to and authorize such medical and dental treatment as may be deemed necessary, and agree to pay for such medical and dental treatment costs.
Parent(s)/Guardian(s) Signature:
Date:
_
YOUTH AGREEMENT:
I accept and comply with all the rules and regulations set down at the event location and by the event organizers. I will honor and respect the people and property associated with this event.
Youth Participant's Signature:
Date:
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