PARENT/LEGAL GUARDIAN PERMISSION SLIP        08/30/17

AND INDEMNITY AGREEMENT

Your sons, daughters, and/or wards are eligible to participate in a school/parish sponsored activity that requires permission.  This activity will take place under the guidance and supervision of
employees/volunteers from St. Agnes and Sacred Heart (parish/school/Diocese of Duluth).

Youth Name: __________________________________________        Grade: ______________

Youth Name: __________________________________________        Grade: ______________

Youth Name: __________________________________________        Grade: ______________

TYPE OF ACTIVITY: Faith Formation 6-12th Grades 2018-2019 School Year

DESCRIPTION OF ACTIVITY: Youth Group of Food, Fun, Teaching and Praying at St. Agnes Church, Walker MN (primary location)  or Sacred Heart, Hackensack MN.  Includes Confirmation classes if applicable to 11th and 12th graders.

DATE AND TIME OF ACTIVITY: Wednesday Evenings 6:00 pm- 8:00 pm (confer calendar)

METHOD OF TRANSPORTATION (IF APPLICABLE): Volunteer Drivers based on activity if required, or bus.

STUDENT COST (IF APPLICABLE):  None


I consent to the participation of my child/ward in the above named activity.  In consideration for my child/ward's participation, I agree to reimburse and indemnify the above named parish/school (understood to include the Diocese of Duluth) for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit.  If the parish/school is found liable for the injuries sustained by child/ward, this paragraph will not apply.

I certify that I have an understanding of this agreement and the risks and hazards associated with the activity described above that my child/ward will be participating in.  I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.

I consent to permission for walking field trips and youth activities within City Limits.

Photography Release Statement

___ I hereby grant permission for my child to be photographed and/or videotaped during Youth Group. I understand that my child may decline to be photographed and/or videotaped at any time. I understand that the resulting photographs and/or videotaped footage may be edited, if necessary, and then published for the purpose of promoting Youth Ministries.

___ I hereby decline to grant permission for my child to be photographed and/or videotaped during Youth Group. I understand that my child may decline to be photographed and/or videotaped at any time. I understand that the resulting photographs and/or videotaped footage may be edited, if necessary, and then published for the purpose of promoting Youth Ministries.

Communication Purposes

___I consent to receive all group communications via text messages for myself as parent and my child’s phone pertaining to youth group information using phone number. (You can text my kids.)

Contacts:         Parent 1 Name:____________________  Parent 1 Cell #_________________________

                

Parent 2 Name:____________________  Parent 2 Cell # _________________________

Youths Name: _______________ Cell Phone Number:_______________________________________

Youths Name: _______________ Cell Phone Number:_______________________________________

Youths Name: _______________ Cell Phone Number:_______________________________________

                                                                                            

Parent/Legal Guardian Name: __________________________________________________________________

Parent/Legal Guardian Signature: __________________________________________Date:_________________

                                                                        

Address: ___________________________________________________________________________________        

City, State,  Zip

Home Phone: ________________________________Work Phone: ____________________________________                                        

EMERGENCY MEDICAL TREATMENT:  In the event of an emergency, I give permission to transport my child/ward to a hospital for emergency medical treatment.  I wish to be advised prior to any further treatment by the hospital or doctor.  In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name and relationship: _______________________________________________________________________        

Phone Number(s): ___________________________________________________________________________

                                        

Medical Insurance Company: __________________________Policy/Group/ID Number: __________________

Please furnish medical or learning needs information about your child/ward which may be pertinent to his or her participation in the above identified activity: (example Allergies)                          

        

Name:_________________________        Information:_______________________________________________


PLEASE RETURN TO: Jamie Richter faithformationSASH@arvig.net  By: September 21st, 2018

Questions please email faithformation@SASH@arvig.net or 218-280-3047.


Please keep this form on file at the diocese for six (6) years.                
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