Church of St. Joseph Youth Group Off Site Permission Slip 2012/2013
Page 2
Name of Teen: ______Date of Birth: ______
Parent/Guardian Name: ______Parent Cell Phone: ______
Address: ______
I give my Son/Daughter permission to attend
Catholic Youth Unite! Roller Skating Party
United Skates of America, Hicksville Rd, Seaford, NY
Sunday, April 2nd 6:00 pm – 8:30 pm
*The Roller Rink will be closed to the public. This is a ticketed event. No Tickets sold at the door.
During the event, if you need to contact your child, the Adult present will be:Barbara McNulty
My child/children will be transported to the event by:
______Myself ___Other: ______
At the end of this outing my child has my permission to be transported home/back to St Joseph:
______byMrs. McNulty in her vehicle ______Myself ______Other: ______
My child is never to leave the premises with: ______
In the event of any emergency or problem occurring during this outing, I can most easily be reached at:
Cell Phone: ______
In the event I can not be reached, the following has permission to act on my behalf:
Name: ______Phone: ______
Please list any allergies, medical conditions, or other circumstances you feel the Adult Chaperones should be aware of to properly supervise your child during this outing: - all information will be kept confidential.
______
To the best of my knowledge, my child is in the best of health and is able to participate fully in all activities.
As a parent and / or legal guardian of the participant named above, I acknowledge that I remain legally responsible for any actions taken by my child. In addition, I agree to defend, protect, indemnify and hold harmless the Diocese of Rockville Centre, the Bishop thereof,Barbara McNulty, the DRVC Youth Ministry Team, the Parish and their respective trustees, officers, employees, volunteers and authorized agents from and against each and every claim, demand or cause of action and any liability, cost or expense (including reasonable attorney’s fees) arising from or in connection with any bodily injury (including death) to my child or any damage or loss to his or her property caused by or arising out of my child attending the event and travelling to/from the event (except as may be caused by the gross negligence of the person or entity seeking indemnity hereunder) or in connection with any illness or injury or cost of medical treatment in connection therewith. I give permission for my child’s photo to be taken and displayed in conjunction with the group activities. I fully understand the consequences of the foregoing statements and sign this form knowingly, freely, and willingly.
(Your signature must appear below or your child will not be permitted to participate in the Event.)
Signature of Parent / Guardian ______Date ______
We Welcome. We Worship. We Witness.
Phone: (631) 669-0068 E-mail Website