Youth Ministry Permission Slip 2024-2025 St. John LaLande

Youth Ministry Permission Slip 2024-2025 St. John LaLande

THIS PERMISSION SLIP COVERS ALL ST. LALANDE YOUTH GROUP EVENTS: PLAYING PHYSICALLY STRENUOUS GAMES, SERVICE PROJECTS, BONFIRES, AT HOME BIBLE STUDIES AND ALL OTHER ACTIVITIES.
Name of Participant*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Birthday

MonthDayYear
Date
Grade
School
Do you give permission for your child to receive youth group related emails?

YesNo
Participant Email (Optional)
example@example.com
Do you give permission for your child to receive Youth Group related text messages or phone calls?*

YesNo
Participant Phone Number (Optional)

Area CodePhone Number
Mother Name (Guardian Name)

First NameLast Name
Mother Email
example@example.com
Mother Phone Number

Area CodePhone Number
Father Name (Guardian Name)

First NameLast Name
Father Email
example@example.com
Father Phone Number

Area CodePhone Number
What is the Participant's T-Shirt Size?
Would you like to be an adult volunteer?

I can host a small group event at my house.I can be a small group leader at the Parish.I can be a second adult at another parents house.I can provide a meal for an event.I can provide a simple snack for an event.I have a relevant testimony that I could share.I am comfortable leading an event on my own.Other
Emergency and Health Information
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
Are you in general good health and able to participate in normal activities?*

YesNo
If No, describe your limitation.
Identify any over-the-counter medications you will be bringing to the event.
All immunizations up to date?*

YesNo
Physician's Name*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
Participant's Health Insurance Provider*
Policy or Group Number*
Primary Policyholder's Name*
Identify any prescription medications the participant is taking and in what dosage and frequency:
Allergies, diseases, disorders, disabilities,surgeries or serious injuries
Permission of Parent/Guardian
Permission or Parent/Guardian For Participation
I/We, the parent(s)/guardian(s) of blanks* , request that he/she be allowed to participate in the events described above, and hereby give my/our permission for such participation.
Do you agree with the above section?*

YesNo
Permission or Parent/Guardian For Photo Release
I/We give my/our permission to the sponsoring Diocese/Parish/School/Organization to take photographs video or digital images of Participant during the Event for future promotional purposes.
Do you agree with the above section?*

YesNo
Consent for Disclosure to Individual Involved in the Care and Treatment of Participant
For the duration of the Event, I/We grant to the Diocese/Parish/School/Organization and its agents the following powers, to be used for the benefit of and on behalf of the Participant.
1. to receive any and all individually identifiable health information about the past, present and future medical condition of Participant, including, but not limited to, information necessary to the care and treatment of Participant and any illness or injury Participant may have sustained
2. to authorize medical care for Participant, including, but not limited to, any and all treatment, examination, diagnosis or outpatient medical care rendered under the general or special supervision of and on the advice of any physician or surgeon licensed to practice medicine by the applicable licensing body in the state in which physician or surgeon practices.
I/We understand that the Diocese/Parish/School/Organization will not be liable to me/us or any or my/our successors in interest for any action taken or not taken in good faith.
I/We consent to the logistics and conditions described above, including the method of transportation.
I/We understand that as parent(s) or legal guardians I/we may be responsible for any liability which may result from the conduct or Participant at or during the event.
I/We understand that there is a risk of injury involved in any Youth Ministry activity. I/We hereby release the Diocese of Kansas City-St. Joseph, and its officers, agents, employees and volunteers, from liability arising from claims of any kind or nature whatsoever in connection with Participant's participation in the Event.
Do you agree with the above sections?*

YesNo
Signature of Parent/Guardian*

Clear
Date Signed*

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Youth Ministry Permission Slip 2024-2025 St. John LaLande

Emergency and Health Information

Permission of Parent/Guardian