Dear Parent or Legal Guardian:
Your son/daughter, guardianship is eligible to participate in a diocesan-sponsored activity that requires
personal transportation to locations away from your home site. This activity will take place under
the guidance and supervision of adult chaperones. A brief description of the activity follows:
ACTIVITY: _______________________________________
DESIGNATED
SUPERVISOR Of ACTIVITY: _________________________________
If
you would like your child to participate in this event, please complete, sign
and return the following
statement
of consent and release of liability. As parent, or legal guardian, you remain
fully responsible
for any legal responsibility
which may result from any
personal actions taken by the named child.
I
hereby consent to participation by my child, _________________________________________
in
the event described above. I understand
that this event will take place away from parish grounds
and that my child
will
be under the supervision of the designated supervisor on the stated dates.
I further consent to the conditions
stated
above on participation in this event, including the method of
transportation.
I
give my permission for my child, in case of an emergency, to be taken to a
physician or hospital by
either the supervisor
in charge or by an adult
chaperone. I understand that every
effort will be made
to contact me. If I
cannot be reached, however, I hereby give permission to the physician selected
by the supervisor in charge or adult chaperone(s) to hospitalize and secure
proper treatment
(including surgery) for my son/daughter. The cost of any necessary medical care or
treatment for
my son/daughter will be my expense.
___________________________________ ____________________
Parent's or Legal Guardian's Signature Date
Phone number where you can be reached in case of emergency_________________________________
Accident/Hospitalization Policy Name
_________________________________________
Policy Number: _________________________________________
Please complete return this entire form by ____________________________________