Permission slip, liability release form
I give permission to my below named son/daughter to attend the event listed below.

If needed for health reasons, I give my permission for my child to be evaluated, diagnosed, treated and/or given medication in accordance with standard medical practice by licensed medical personnel. I relieve Immaculate Heart of Mary and St. Joseph the Worker church liable in the event of injury. Further, I agree to accept any and all financial responsibility as a result for scheduling medical treatment.

My child agrees to abide by all the rules and regulations given by the group organizer of Immaculate Heart of Mary and St. Joseph the Worker. I understand that Immaculate Heart of Mary and St. Joseph the Worker will not be liable if my child fails to cooperate with regulations and that any infraction of the rules may result in immediate dismissal from the retreat.

Event *
Your answer
Parent's Signature *
Your answer
Participant's Name *
Your answer
Date of Birth *
Your answer
Address *
Your answer
Please check one *
In case of emergency, please contact (include name, address, phone#): *
Your answer
Family Physician and phone # *
Your answer
Allegeries *
Your answer
Current medications *
Your answer
Medical Insurance Co/ Contract/ Group # *
Your answer
Preferred Hospital *
Your answer
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This form was created inside of Roman Catholic Diocese of Syracuse.