Permission Slip

FIELD TRIP

Participant’s Name:

__________________________________________

Birth Date: ________________________________

Sex: ______________
Parent/Guardian’s name:

_______________________________________________
Home address:

_______________________________________________

Home Phone: __________________________
Cell phone: ____________________________
Date/Type of event:

_______________________________________________
Destination:

_______________________________________________

Individual(s) in Charge:

_______________________________________________

Estimated time of departure and return:_________________________________________

Mode of transportation to and from event: _______________________________________________

Student cost if applicable:

_______________________________________________

I, _____________________________________________,
grant permission for______________________________
(Parent or guardian’s name) (Child’s name) to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to indemnify the parish and the Archdiocese of St. Paul/Minneapolis from any claims or law suits brought against the parish/Archdiocese of St. Paul/Minneapolis 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 orexpenses incurred by the parish and Archdiocese in defense of such aclaim/law suit.
EMERGENCY MEDICAL TREATMENT: In the event of an

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

_______________________________________________

(Name) (Phone number) OPTIONAL MEDICAL INFORMATION: Medication my child is taking at present:

_______________________________________________

Family Health Plan carrier number:

_______________________________________________

Family Doctor:
_______________________________________________

Phone number:_________________________________
As a parent or guardian, I agree to all the above stated
consideration and conditions.

_______________________________________________
(Signature) (Date)

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