Archdiocese of Baltimore
CHURCH OF ST. JOHN THE EVANGELIST
OFFICE OF RELIGIOUS EDUCATION/YOUTH MINISTRY
Students Name: ____________________________________ Home Phone: ________________________
Date of Birth: _________________________ Social Security #______________________
Parent(s) Name:_____________________________________ Work Phone: ________________________
Other # where Parent(s) can be reached: _________________________________________________________
Home Address: _________________________________ญญญญญญญญญญญญญญญญญ______________ City/State/Zip____________
In case of emergency, when parent(s) cannot be reached, please contact:
__________________________________________________________________________________________
Name (relationship) Phone Number
In consideration of the wholesome spiritual, recreational and learning experience in which my son/daughter will participate, I/we, as parent(s) or guardian(s) of _________________________________ do hereby agree to allow my son/daughter to travel by bus and accompany the Confirmation Class to their Retreat to:
Sparks, MD 21152
I/we understand that students will be assigned to one of the following Retreat dates:
March 6 or April 3, 2005
I/we acknowledge receipt of information describing the planned activities.
In consideration of the opportunity for my son/daughter to participate in this activity, I/we agree to release and hold harmless and indemnify the Church of St. John the Evangelist, William H. Keeler, Roman Catholic Archbishop of Baltimore and his successors, a corporation sole, and their directors, officers, agents and employees from any liability, claims, demands, actions and causes of action arising out of or relating to any loss, damage or injury sustained in connection with my son/daughter’s participation in this activity.
In the event of a medical emergency, where I/we cannot be contacted, I/we hereby give my/our consent to the accompanying adult chaperones to authorize medical treatment of my/our child. I/we have provided the name of an additional person to contact under such circumstances, and have noted special health considerations below.
q My/our son/daughter is covered by hospitalization and medical insurance under policy #_______________ issued by _____________________________________________
q I/we do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my/our son/daughter.
I/we grant permission to any staff person or adult chaperone to provide the following over the counter medication to my son/daughter if requested by my son/daughter (check all that apply):
___Tylenol ___Benadryl ___Advil ____Sudafed ____ Midol ____Kaopectate ____Neosporin
Please specify any health considerations, dietary restrictions or allergies to medication, which may apply to your son/daughter
_________________________________________________________________________________________________
Witness our hands and seals this _______ day of _________________, 200__.
Father (Guardian):__________________________________________________________________________
Mother (Guardian):_________________________________________________________________________