Bloomington Winter Games (2017) Permission Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Church of St. Edward
Bloomington Winter Games (Fourth Annual)
For grades 10-12

Email *

Date of Field Trip

Sunday, February 12, 2017

Times

To be determined

Student Cost

$30 (for uniforms only)
Note: If you already have the uniform from last year, there is no cost to you. Just wear your sweatpants, hat and shirt.

Location

Tarnhill Park

Individuals In Charge

Patrick Smalley
Youth minstry staff from other Bloomington churches

Participant

Student/Participant Name *

Participant Date of Birth *

YYYY

Participant Gender

Participant Grade

Parent / Guardian (1)

Parent/Guardian Name (1) *

Home Address (1) *

Primary Phone (1) *

Email Address (1) *

Parent / Guardian (2)

Parent/Guardian Name (2)

Home Address (2)

Primary Phone (2)

Email Address (2)

Health & Medical Information

The Church of St. Edward will take reasonable care to see that the following information will be held in confidence. Please type "None" where applicable.

Medication my child is taking at present: *

For headache or minor pain, my child may be given: *

List allergies: *

Allergic reactions (medications, foods, plants, insects, etc): *

Immunizations: date of last tetanus/diphtheria immunization

Does child have a medically prescribed diet? *

If yes, please describe:

Any physical limitations? *

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? *

If so, date and disease or condition:

Special medical conditions of my child: *

Other medical conditions:

Insurance Company: *

Family Health Plan Carrier Number: *

Family Doctor:

Phone Number:

Medical Statements

To be completed by Parent / Guardian

Of the following statements pertaining to medical matters, check only those that are applicable:

Medical Treatment: In the event it comes to the attention of the Church of St. Edward, its officers, directors and agents, and the Archdiocese of Saint Paul & Minneapolis, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are indicated above.

I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Emergency Medical

To be completed by Parent / Guardian. In the event of any emergency, if unable to reach Parent/Guardian at the phone number(s) listed above, contact:

Name: *

Relationship: *

Phone Number: *

Emergency Medical Parent Consent: *

Yes, in the event of an emergency, I give permission to transport my child to a hospital. I agree to allow my child to receive emergency medical treatment at my expense at the discretion of the event sponsor. I wish to be advised prior to any further treatment by a doctor or hospital.

Required

Please further indicate your consent by providing your initials below: *

Parent Consent

To be completed by Parent / Guardian

In consideration of my child's participation in the above-described event: *

I hereby warrant that, to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

I agree to indemnify the Church of St. Edward from any claims or law suits brought by myself, my child, or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney’s fees or expenses incurred by the parish/school in defense of such a claim/suit.

I agree to drop my child off at the departure location at least 15 minutes prior to departure and to provide transportation home at my expense.

I agree that I am responsible for my child’s conduct and actions. The event sponsor is not responsible for any injury or damage incurred or caused by my child. I understand that my child is required to comply with the Code of Conduct provided by the Church of St. Edward while participating in the event. I understand that if my child violates the Code of Conduct he/she may be required to be transported home at my expense.

I agree that if any of the terms outlined in this form are violated, the Church of St. Edward can send my child home at the my expense.

I authorize and consent that the Church of St. Edward and the Archdiocese of Saint Paul and Minneapolis be permitted to use My Child’s first and last name along with My Child's likeness that is published through any medium for communications or publicity purposes or for any other lawful purpose whatsoever, including social or other electronic media, in accordance with the Archdiocesan Acceptable Use Policy for Electronic Communications and the Social Media Policy.

Required

By checking the boxes above and adding my initials below, I accept all terms pertinent to parent/guardian, as outlined in this form. *

Electronic Signature *

I acknowledge that my initials represent an electronic signature that is intended to represent my legal signature. I accept all of the terms in this agreement and my initials (electronic signature) confirms my acceptance.

Required

Participant's Code of Conduct

This section is to be completed by the participant. The following are a few rules that all participants are expected to follow while participating with and representing the Church of St. Edward.

By checking each of these boxes and adding my initials below, I (participant) indicate my agreement to follow this Code of Conduct: *

Treat all other persons with respect and not cause any intentional harm (physically, emotionally, or spiritually) to any person in any way.

Respect the property of others, including all program facilities and property.

Follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration.

Be on time for all check-ins and departure time.

Not have in my possession any tobacco, alcohol or any controlled illegal substance.

Required

By checking each of the boxes above and adding my initials below, I (participant) agree to follow the Code of Conduct as stated above. *

Electronic Signature *

Required

Thank you!

The Church of St. Edward, sponsor of this activity, is responsible for receiving an authorized form for each participant under the age of 18, if deemed necessary for overnight events or other activities requiring responsible behavior.

Be sure to click the blue "Submit" button!

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms