Archdiocese of Portland/St. Anthony Parish
 Parent/Legal Guardian Event Permission Slip
for Student/Youth

 

Event :  Caroling at Good Shepherd homes      Location: Forest Grove & Cornelius

Date of Event:  December 17, 2006                    Departure time:  7:00pm from the Youth Center
Mode of transportation:   Private Cars        Estimated time for end activity: 9:00pm

Cost:  Bring an ornament to give to residents of home

Parents:  We need drivers.  Please call the office to volunteer.

To be completed by Parent/Legal Guardian

 

I_______________________________The undersigned, give my permission for _____________________________    

                  (Parent /Guardian)                                                                                                   (son or daughter)

to take part in an off-premises event which will require transportation and supervision by Archdiocesan/St Anthony employees and volunteers.
 

·         I agree to allow my child to participate in this event.

·         I agree and understand that transportation may be provided in such form
and at the discretion of the Archdiocese of Portland/St. Anthony

·         I also authorize the Archdiocese of Portland/St. Anthony and its
employees or chaperones to secure any and all necessary medical services for
my child in the event of an accident or illness. Further, I agree to be
solely responsible for the payment of those services.

 

Youth’s name________________________________Date of Birth__________________ Sex  Male: y   Female: y

Allergies:(foods, drugs, insects, etc.)_________________________________________________________________

 

_______________________________________________________________________________________________

Medications (name, dosage, reason)__________________________________________________________________

 
_______________________________________________________________________________________________

Other information (injuries, etc.)____________________________________________________________________

_______________________________________________________________________________________________

Insurance Carrier__________________________ Group or ID#___________________________________________

In case of emergency, please notify:

Parent/Guardian_____________________________Phone_(D)_____________________(N)____________________

Youth’s
Doctor____________________________________ Phone_______________________________________________

 

 

_______________________________________________________________________________________________
(Parent/guardian signature)                                                          (Date)