Receive and Remain Permission Form

ST. HELEN LIFE TEEN
“R & R” - Receive and Remain

Sacred Heart Chapel, Center for Pastoral Leadership

Mass, Pizza & Night Prayer

January 25, February 22, April 25

Meet in the St. Helen parking lot 6:00pm. Approximate return time 9:45pm

Name

Home Address

Home phone

Teen Cell Phone

Date of Birth

Date

High School

Grade

Parent/Guardian Name:

Parent/Guardian Cell Number

Parent/Guardian Email

example@example.com

If we cannot be reached in case of emergency, please call:

Name

Relationship to Minor

Address

Phone

Consent Form and Liability Waiver
I, as the parent or legal guardian of First Name Last Name do hereby grant permission for my child to participate in the St. Helen Parishes Receive and Remain trip. I acknowledge that the aforesaid participant will be involved in physical activities that may cause injury and that there may be risks foreseen and unforeseen. I agree by .my signature to release, absolve, indemnify, and hold harmless St. Helen Parish, Newbury, Ohio, their employees and agents; The Roman Catholic Diocese of Cleveland; The Bishop of the Roman Catholic Diocese of Cleveland their successors, and assigns from any and all liability for injury, medical fees, hospital bills, or doctor bills of aforesaid participant as well as all debts, claims, demands, costs, expenses, damages, actions, and causes of actions -- I waive all claims of any kind against those mentioned.

Parent/Guardian Signature

Date

Authorization for Medical Treatment

I, as parent or legal guardian of First Name do hereby give my consent for St. Helen Parish Staff and the chaperones, or other adult representative, in the event that all reasonable attempts to contact me have been unsuccessful, to seek medical attention and treatment deemed necessary by medical personnel. I give my permission to transfer my child to the nearest hospital.

Our healthcare insurance carrier is provider. This authorization does not cover major surgery, unless the medical opinion of two other licensed physicians concur on the necessity for such surgery and are obtained before surgery is performed.

Please list allergies and medical conditions or dietary restrictions:

List any medications and dosage child is currently taking

Parent/Guardian Signature

Date

Photo Release - St. Helen Church

I/We, the parent(s) of the above, give my/our permission to St. Helen Parish, Newbury, Ohio to publish my/our child's photo only (no name) in publications/media forms listed below exclusively for the purpose of St. Helen Parish and its parishioners. Slideshows, Parish Bulletin, Parish Website, Narthex TV, etc.

Photo Release - St. Helen Church
I/We, the parent(s) of First Name Last Name , give my/our permission to St. Helen Parish, Newbury, Ohio to publish my/our child's photo only (no name) in publications/media forms listed below exclusively for the purpose of St. Helen Parish and its parishioners. Slideshows, Parish Bulletin, Parish Website, Narthex TV, etc.

Signature