Chorus Redemptoris Permission Form
Student's Name *
Your answer
Student's Grade *
Mother's First Name *
Your answer
Mother's Last Name *
Your answer
Mother's Work Phone *
Your answer
Mother's Cell Phone *
Your answer
Mother's Email *
Your answer
Father's First Name *
Your answer
Father's Last Name *
Your answer
Father's Work Phone *
Your answer
Father's Cell Phone *
Your answer
Father's Email *
Your answer
Home Address *
Your answer
Home Phone *
Your answer
Name of Insurance *
Your answer
Policy Number *
Your answer
Name of Insured *
Your answer
Physician's Name and Phone Number *
Your answer
Drug Allergies *
Your answer
Other Medical Concerns *
Your answer
In Case of an Emergency, Contact #1 (Please provide all contact information for someone other than the parents) *
Your answer
Who will be picking this person up from the Activity? (If someone other than the people listed here, you will need to provide the name in a note that you send with the child) *
Your answer
I grant permission for my child (listed above) to participate in extracurricular activities. These activities will take place under the guidance and direction of school employees and/or volunteers. As a parent and/or legal guardian, I remain legally responsible for personal actions taken by the above named minor (“student”). I agree on behalf of myself, my child named herein, our heirs, successors and assigns, to hold harmless and defend, Christ the Redeemer Catholic School, its employees, officers, directors and agents, and the Archdiocese of Galveston-Houston, or representatives associated with these activities, arising from or in connection with my child participating in these activities, or in connection with any illness, injury or cost of medical treatment in connection therewith, and I agree to compensate Christ the Redeemer Catholic School or representatives associated with the activity for reasonable attorney’s fees and expenses arising in connection therewith *
I hereby warrant to the best of my knowledge, that my child is in good health, and I assume all responsibility for the health and medical care of my child. In the event of a medical emergency, I hereby give permission to school employees and/or volunteers supervising the extracurricular activity to obtain medical services and to transport my child to the nearest hospital/emergency care center for emergency medical or surgical treatment. *
Signature (By typing your name you are creating an electronic signature for this document) *
Your answer
Relationship to Student *
Your answer
Date *
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