Teen Permission Form 2020

Teen Permission Trip Form 2020

Teen's First Name*
Teen's Last Name*
Gender*
Age At Time Of Camp*
School Grade 2020-2021*
Teen Email*
Home Phone*
Teen Cell Phone*
Address*
Street Address Address Line 2 City State ZIP Code
T-shirt Size*
Parent's Name(s)*
Mother E-mail*
Mother Cell #*
Father E-mail*
Father Cell #*
Emergency Contact Name and Phone Number, if unable to reach parent:
Emergency Contact Name*
Emergency Contact Phone Number*
Physician*
Physician Phone*
Insurance Policy #*
Allergies or Medical Conditions
Please list if applicable.
PERMISSION & AUTHORIZATION FORM FOR MEDICAL TREATMENT
I/We, the parent(s)request that Holy Family Teen Faith program allow my/our child to participate in Catholic Heart WorkCamp Summer Mission Trip in Farmington, MI June 21-26, 2020 I hereby release and indemnify Holy Family Parish, its staff and its volunteers and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this event. In the event that the undersigned or my (our) authorized physician, cannot be reached, and in the judgment of a responsible person accompanying the group, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child, I/We hereby authorize any of the aforesaid people to obtain for my child such medical services as are deemed necessary.
Confirm Consent*
I agree
*
- I understand that a minimum of a $100 deposit is due at the time of registration or my son/daughter’s spot will not be held.
- I understand and agree to pay the final balance of this trip by April 1, 2020.
Date*
MM slash DD slash YYYY
I have read and understand the rules and agree to comply with them.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.