Hosting Region 4 Parish: Blessed Kateri
Parish: Our Lady of Mount Carmel Phone:
595-0385x128
Address: 100 Harpersville Road City:
Newport News Zip: 23601
Type of Event: day trip to Massanutten
Destination: Massanutten, outside of Harrisonburg, VA
Individual in Charge: Pat Kovac
Place of Departure: Kateri Estimated Time of
Departure: Sunday 4:30 am
Dates of Trip: Jan 9, 2005 Estimated Time of Return: Sunday 10:00 pm
Mode of Transportation to and from the event: chartered bus
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_________________
(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.