Parental Agreement and
Permission Slip

Youth Name__________________________________________________________ Male Female (please circle)
Parent(s) Name___________________________________________________
Home Phone__________________ Work Phone_______________ Other Phone_________________
Address________________________________________________ Zip______________
Youth D.O.B.___________ Youth S.S.N.______________ Check one:
YouthGroupMember
Guest

In consideration of the wholesome recreation and learning experience in which my child will participate, I/we as parent(s) or guardian(s) of the above named youth do hereby agree to allow my child to accompany Youth Group to their organized group trip or activity: _______________________ on ______________________. I/we acknowledge reciept of an information sheet describing the planned events.

In consideration of the opportunity for my child to participate in this activity, I/we agree to release and hold harmless and indemnify Saint Francis de Sales Church of Abingdon, William H. Keeler, Roman Archbishop of Baltimore and his successors, a corporation sole, and their directors, officers, agents and employees from liability, claims, demands, actions and causes of action arising out of or relating to any loss, damage or injury sustained in connection with my child's participating in this activity.

I hereby grant permission to Paula M. Nash, the group's adult supervisor in charge, to obtain medical care from a licensedd physician, hospital or medical clinic for my child in the event that I cannot be reached (Check one of the following):

   
My Child is covered by hospitalization and medical insurance issued by ___________ under policy number___________. The policy holder is _______________.
   
I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my child.

I hereby granty permission to any staff person to provide the following over-the-counter drugs to my child if requested by my child
(Check all that apply):
                                           
Tylenol    
Benadryl    
Advil    
Sudafed    
Midol    
Kaopectate    
Neosporin

Add any other information concerning medication, allergies, illness, dietary restrictions, etc.: ___________________________________________________________ _______________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________

Parents/guardians of participants are advised that photographs or videotapes may be used in publications, websites or other materials produced from time to time by the Youth Ministry Office (pParticipants would not be identified, however, without written consent). Parents/guardians who do not wish thier child(ren) to be photographed or filmedd should notify the Youth Ministry Office in writing. Please note the Youth Ministry Office has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate.

_____________________________________________             _____________________________________________
Parent/Guardian Signature             Date                                                   Parent/Guardian Signature             Date