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Holy Family Catholic Church

Diocese of Charlotte, NC

PARENTAL/LEGAL GUARDIAN PERMISSION FORM FOR YOUTH EVENT PARTICIPATION

Dear Parent or Legal Guardian:

Your son/daughter/guardianship is eligible to participate in a Holy Family Youth-sponsored activity. This activity will take place under the guidance and supervision of adult chaperones.

ACTIVITY:

DATE(S):

DESIGNATED SUPERVISOR OF ACTIVITY:  Andrew Salvetti

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 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

Two phone numbers where you can be reached in case of an emergency.

Your child’s full name

Your Email

Accident/Hospitalization Policy Name

Policy Number

**Please write on reverse any medical (or other) conditions of which the chaperones should be aware.**

Copy and paste this text into a Word document. Please print and return to the Office of Youth Ministry. Thank you!

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