Participant Information:

Name:

Street:

City:                                                                         State:                                                     Zip:

Phone:                                                  Date of Birth:                                                                   Grade:

Name(s) of Mother & Father (or legal guardians):

Parent’s address (If different from your own):

Street:                                                                      Phone:

 City:                                                                         State:                                                     Zip:

Insurance Company:                                                                         Policy Number:

Activity Information (be specific):

Parish/Organization:

Activity:

Place:                                                                                                                      Date of Activity:

Adult Chaperone:                                                                                          Day of Event Phone:

Permission and Medical Treatment Waiver

I, _______________________, the parent/guardian of _________________ do hereby give my permission for him/her to attend the above activity and to be treated for a medical emergency in my absence while participating in the Youth Ministry program. The Youth Minister or Adult supervisor may act as an agent in my absence. In case of accident, I do not hold the Diocese of Gary, the parish, its staff, or the adult chaperones responsible.

In case of emergency, if I am not available at the above address and phone, please contact:

Name:                                                                                                                    Phone:

Parent/Guardian Signature:                                                                                            Date:

Special Dietary Needs:

Medications: __________________________________________ Allergies:__________________________________________