CYM PERMISSION SLIP, JULY 2008/2009

Use this permission slip for on site events ONLY

I/We, the parent(s)/guardian(s) of _____________________________________________request that St. Elizabeth Ann Seton CYM allow my/our son/daughter to participate in ROC or AWOL activities at St. Elizabeth Ann Seton.

Chaperones will accompany the event leader.

I/We understand that I/We are responsible for arranging my son/daughter/s transportation to the activity.

I/We hereby release and hold St. Elizabeth Ann Seton Church harmless as well as any and all of its employees and volunteers from any and all liability for any and all harm arising to my/our son/daughter as a result of this event.

Date: ________________________________________________

Parent/Guardian

Signed: ___________________________________________Emergency Phone#_________________________

Cell #____________________________________________

Signed:___________________________________________ Emergency Phone#_________________________

Cell#____________________________________________

Emergency Contact

Name: _______________________________________________ Phone:________________________

Cell# _________________________________________________

Medical Information

Dr __________________________________________ Phone ____________________________________

Hospital ______________________________________ Insurance # ________________________________

I/We further authorize emergency medical treatment for my/our Son/daughter should the need arise while on this trip. (List any medication or special medical condition that medical personnel may need to know in case of an emergency.) 

Medication:___________________________________________________________________________

Medical condition(s)___________________________________________________________________________

Date:_____________________________________

Signed:_____________________________________________ Signed:___________________________________

RETURN PERMISSION SLIP TO: SARA CARTER, SEAS YOUTH MINISTER

2200 W. REPUBLIC RD, SPRINGFIELD, MO  65807

887-6472 ext 208