As the parent/legal guardian of ____________________________ permission is hereby given for my child to go on a Parish trip to: Bowl America on January 28, 2007. The meeting time will be at 7:00pm and the pickup time will be at 9:00pm.
I understand and acknowledge that participation in the
activities involves inherent risks of injury to my child including risks
associated with transportation by motor vehicle. I agree to indemnify the
Parish, Youth Ministers, Volunteers, and the Diocese of Arlington for any costs
or expenses arising out of my child’s participation in the activities including
the cost of any medical care given my child or any expenses or fees incurred in
any lawsuit arising as a result of any damage or injuries caused by my child in
the course of his or her participation in the activity. I further give my
consent to that in my absence the above-named minor be admitted to any
hospital or medical facility for diagnosis and treatment. I request and
authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine
or Doctors of Dentistry or other such licensed technicians or nurses, to
perform any diagnostic procedures, treatment procedures, operative procedures
and x-ray treatment of the above minor. I have not been given a guarantee as to
the results of examination or treatment. I authorize the hospital or medical
facility to dispose of any specimen or tissue taken from the above-named minor.
I authorize the Diocese of Arlington to
use my child’s picture or video recording for educational and/or marketing
purposes. Parents/guardians who do not wish their child to be photographed or
filmed should so notify the St. Philip Catholic Church Office of Youth Ministry
in writing.
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Date
of Birth |
Date
of last Tetanus Booster |
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Known
allergies including any allergies to medicine (Continue on back of form if
needed) |
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Any
other medical problems which should be noted (Continue on back of form if
needed) |
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Name
of Parent/Guardian |
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Address |
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City/State/Zip |
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Phone
Home
Work Mobile |
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Person
responsible for charges (if different from above) |
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Address |
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City/State/Zip |
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Phone
Home
Work Mobile |
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Person
to notify if parent/guardian is unavailable |
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Phone
Home
Work Mobile |
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Family
Physician Phone |
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Insurance
Carrier & Policy Number |
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Signature
of Parent |
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Date |
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Signature
of Witness
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Date |
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