Confirmation Year 1 (Making a Difference) Retreat Permission Slip

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

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

Type of Event: retreat for Year 1 Confirmation Candidates

Destination: St. Jerome's, Newport News, VA.

Individual in Charge: Angela Hamrick

Transportation: You are responsible for your own transportation to and from St. Jerome's.

Date of Trip: Feb. 20, 2005

Retreat Info: Registration begins at 1 p.m. Dinner. Mass. Retreat ends at 8 p.m.

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_____________________________________________________

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

(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.