March for Life 2005 Permission Slip

Parish: Our Lady of Mount Carmel                   Phone: 595-0385x128

Address: 100 Harpersville Road                       City: Newport News                Zip: 23601

Type of Event: trip to DC for March for Life and Youth Rally/Mass

Destination: Washington, DC

Individual in Charge: Angela Hamrick

Place of Departure: OLMC      Estimated Time of Departure: 2:00pm

Dates of Trip: Jan 23-24, 2005            Estimated Time of Return: 10 pm

Mode of Transportation to and from the event: vans/cars

Parental/Guardian Consent Form and Liability Waiver

Participant's Name________________________________________________________

Sex                  Date of Birth                             Age________________________________

Parent/Guardian's Names___________________________________________________

Home Address____________________________________________________________

City                                                      State                Zip___________________________

Home Phone                                                    Work Phone__________________________

Number parent/guardian can be reached on date of event__________________________

Emergency Contact Person                                                       Phone___________________

Relationship to participant___________________________________________________

Email address____________________________________________________________

I (parent,/guardian above) grant permission for my child (participant above) to participate in this parish youth ministry even that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of the parish employees and/or volunteers. A brief description of the activity is give at the top of the page.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by my child. I agree on behalf of myself, my child name herein, or our heirs, successors, and assigns, to hold harmless and defend this Parish (listed above), its officers, directors, and agents, and the Diocese of Richmond, Virginia, chaperones, or representatives associated with this event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Diocese of Richmond, chaperones, or representatives associated with the event for reasonable attorney's fee and expenses arising in connection there within.

Signature                                                                                              Date_________________
 

Chaperone/Transportation
I am able/unable to help chaperone and drive for this trip
My vehicle holds this many passengers including myself_____________________
Name:________________________Email:_______________________Phone:_____________________

Note: Does the youth minister have a copy of your medical release form on file? (You filled one out if you registered for RE this year). If not, make sure you get one filled out before the trip.