On Site Activity Form Awake a Thon All Saints on the Hudon Faith Formation

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 ALL SAINTS ON THE HUDON FAITH FORMATION/YOUTH MINISTRY ACTIVITY/PROGRAM ACTIVITY/PROGRAM PERMISSION ± RELEASE & CONSENT FORM

I, ___________________________the parent or guardian of_______________________________  (Name of parent/guardian)

(Name of child/youth)

a child/youth at__________________________ Parish, hereby grant permission for the above child/youth to attend an AWAKE A THON_FUNDRAISER at All Saints South Parish Center, Chaperoned by Youth Ministry Adults_ on Saturday, March 10, 2012 from approximately, 7:00PM__ to Sunday, 7:00AM, 7:00AM, and I consent to his/her participation in this onsite activity/program. Since this event is a 12 hour activity ****it is strongly recommended that your child do not drive themselves home. I understand that my youth will get to the place of the program and picked up by ______________________________________________  (Parent or authorized adult) I authorize the employees, representatives and chaperones of  All Saints on the Hudson Parish to obtain emergency medical treatment, should it be necessary, during my child¶s attendance and participation in above program. I understand that I will be notified immediately should it become necessary to obtain emergency treatment. The person(s) who should be notified and the telephone number(s) are: Name_________________________________________ Phone _______________  Name _________________________________________ Phone _______________  I fully understand what is involved in this trip, and I understand that I have the opportunity to call Vickie Giulianelli at 664-3191 youth minister and her about the activity/program. In case of an emergency, I can be reached at _____________________________________.

print)  Allergies MEDICAL INFORMATION (please type or print) Allergies  ______________________________________________________________________________  Required medication (please indicate dosages, frequency, etc.) ___________________________   ______________________________________________________________________________ Special Medical Conditions _______________________________________________________   ______________________________________________________________________________  Insurance Carrier: _________________________ Policy Carrier: ________________________  Policy Number   _____________________________________  Date of last tetanus booster ___________________   

____________________________________________

_____/_____/_____ 

Signature of parent/guardian (PLEASE SEE BELOW SIDE)

RELEASE AND CONSENT FORM ² CONTINUED

Parent (please print) I will not hold All Saints on the Hudson Parish or the leadership person and volunteers responsible in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment. . I fully understand the consequence of the foregoing statements and sign this PARENTAL/GUARDIAN CONSENT FORM/ LIABILTY WAIVER, knowingly, freely, and willingly.

My child agrees to abide by all rules and regulations decided upon by All Saint on the Hudson parish and the leadership personnel of the event. I understand that neither the parish of All Saint on the Hudson nor the leadership personnel of the event will be held liable if my child fails to cooperate with said regulations and that any in fractions of the rules may result in immediate dismissal from the event. I further understand that I will be responsible for any costs or other requirements for immediate transportation home.

(Your signature must appear below or your child will not be permitted to participate in the Youth Ministry Awake a thon.

Signature  _________________________________________ Date _____________________ 

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