Permission Form/ Liability Waiver

Name of Event: SJW/HF Lock-In

Destinations: SJW Church, WOW Zone

Group Leader: Ed Snyder

Dates/Times:May 19, 4:45 PM – May 20, 7:30AM

Method of Transportation:Chaperone drivers/vans/other methods

In consideration of the opportunity for my child to participate, and fully recognizing that such an undertaking involves an element of risk, I/we assume all risks and hazards incidental to such participation and do herby release, absolve, indemnify, and agree to hold harmless the St. Joseph the Worker/Holy Family Catholic parishes, the Diocese of Winona, its agents, employees and officers and the chaperones, leaders, organizers, and sponsors and people transporting our child to and/or from these activities.

I hereby consent to participation by my child ______in the event described above. I further consent to the conditions stated above on participation in this event, including the method of transportation. In the event of an emergency and I/we cannot be contacted, I/we hereby authorize that emergency treatment may be administered.

I also grant permission for photographsor video of the minor(s) above to be used for public display as the church deems fit. (ie: website, newsletters, or other means)

(Please include a copy of the participant’s medical insurance card, both sides, with this form, in the return envelope). The following are special circumstances regarding my child that you should be aware of:

______

______

Name of Participant: ______

Address: ______

Phone: ______

Emergency Contact Person: ______

Emergency Phone: ______

Parent/Guardian Signature: ______

Date: ______

One of my parents can be a: Chaperone Driver (5:30 PM- 11:30 PM) ______

Night Chaperone (11:30 PM -7:30 AM) ______

Code of Conduct: Lock-In

Whenever we travel we represent our parish and our Catholic faith. In consideration of this, please read and sign the Code of Conduct for our trip. Any violation of this code will result in being sent home immediately without a refund.

Behavior for the Whole Event:

  1. Participants will immediately obey the directions of all chaperones.
  2. Participants are NEVER to be alone. Participants will always have a “buddy” or group of “buddies” with them.
  3. Participants are NEVER to be in a private place with a member of the opposite sex (adult or minor).
  4. Participants and Chaperones will notify Ed immediately if there is a problem or concern.
  5. Participants will respect all property and individuals. (Vandalism, damage due to carelessness and physical harassment are not tolerated)
  6. Participants will “check-in” and not leave the event without notifying Ed directly.
  7. Participants will adhere to the “Bring/Don’t Bring” list.

At the Wow Zone:

  1. Participants will wear BOWLING SHOES when bowling.
  2. Participants will wait patiently in lines.
  3. Participants will obey Wow Zone Staff.

At the Church (Middle School):

  1. Middle School Students may only be in approved areas.
  2. Middle School Students may not share sleeping bags or pillows.
  3. Participants will refrain from loud noises while outside.

At the Church (High School):

  1. High School Participants may only be in approved areas.
  2. No boys in the girl’s room or girls in the boy’s room.
  3. Participants will refrain from loud noises while outside.

By signing this you agree to the Code of Conduct and state that you understand the consequences of violating that code.

______

Youth/Adult Participant Signature Parent/Guardian Signature

Bring:

  1. Sleeping Bag
  2. Pillow
  3. Tooth brush/toiletries needed
  4. Pocket money (for the Wow Zone if you wish to play games or buy food)

Do NOT Bring:

  1. Electronics (games, iPods, etc.)
  2. Weapons/Drugs/Alcohol or anything not allowed in school
  3. Air Mattresses