Northern Points Cluster
518-494-5229 Ext. 33 Cell Phone:
518-796-7075
Parents are to keep top half:
Please complete the second
page of the Permission Slip, and return to Barb Carlozzi. This first
page can be kept for your reference.
(Name of event)
On ___________________,
__________________________________________________. We will leave
_________________
(Day of Week) (Date 00/00/04) (Parish
center)
at __________________, and will return at ________________________, at the same parish center.
(time am or pm) (time am or pm)
If there is a conflict in
arrival of time back to the parish center, we will call 30 minutes prior to
arriving. Please call
the cell phone, and leave a message if any conflict arises during the
event.
We will get back to you, if
necessary.
Barbara Carlozzi, Youth Minister is the leader of this event.
My son/daughter ________________________________________________ has my permission to attend
________________________________________________ with Northern Points Cluster Youth Ministry.
(name of event)
During the
________________________________, I may be reached at ( ) ______________________
or I may be reached at (
) _____________________________________.
Emergency Contact
Information: Provide a contact other
than parents:
_______________________________________________________________________________________
(Name)
(Relationship)
___________________________________________________________________________________________________________________
(Phone Number) (Alternative
Phone Number)
___________________________________________________________________________________________________________
Insurance Carrier:
______________________________________________________________________
Policy Carrier:
_____________________________ Policy Number: ______________________________
Date of last tetanus booster:
________________________
Please list any allergies,
medications or medical conditions:
______________________________________________________________________________________
____________________________________________________________________________
I
_________________________request that my son/daughter,
___________________________________________,
participate in youth events and give permission for them to do
so. I will not hold the Diocese,
chaperones, or representatives associated with the church/cluster responsible
in the event of injury. My son/daughter
agrees to abide by the rules and regulations decided upon by church/cluster
representatives. I understand that the
parish/cluster nor the leadership personnel is not to be held liable if my
child does not abide by said regulations and if my youth acts inappropriately
and is asked to leave the event, it is my responsibility to transport them
home.
If needed, I give permission for my
child to be transported in privately owned vehicles. I also give permission for qualified medical
personnel to evaluate, diagnose, treat and/or medicate my child in accordance
with standard medical practice and for release of medical record to an
attending physician in case of illness.
I further agree to accept any and all financial responsibility as a
result of scheduling such treatment. In
cases of medical emergency, I understand that every effort will be made to
first contact the parent or guardian, then the emergency contact. In the event that I cannot be reached, I
hereby give permission to the physician selected to secure proper treatment for
my child named herein.
____________________________________________________
(Parent/Guardian Signature) (Date)