Water Walk Permission Slip
As a part of our YM lesson on Sunday, March 10, we will be taking the students on a "Water Walk." We will be simulating what's it's like for women and children in water-scarce countries like India who have to walk (sometimes miles!) to get water for their families. We will be walking with buckets from Blessed Sacrament to Plymouth Park, where a volunteer will be waiting with a trough of water. We will fill our buckets and carry them back to Blessed Sacrament. Since we are leaving Blessed Sacrament property for this lesson, we need each student to have parental permission to participate.
Date and Time of Event
Sunday, March 10, 6-8pm
Destinations
PLYMOUTH PARK: 1508 E Wheeler St, Midland, MI 48642
Supervisors
Christine Sellnow and Kathy Russell
Name of Child
*
First Name
Last Name
Age
*
Allergies
*
Medical Conditions
*
Medicines child is currently taking
*
Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage.
Name of Child 2
First Name
Last Name
Age of Child 2
Allergies of Child 2
Medical Conditions of Child 2
Medicines Child 2 is currently taking
Name of Child 3
First Name
Last Name
Age of Child 3
Allergies of Child 3
Medical Conditions of Child 3
Medicines Child 3 is currently taking
Permission to Participate
I, the parent of the child(ren) listed, request that Blessed Sacrament, Assumption BVM, and St. Brigid Parishes allow my son(s)/daughter(s) to participate in the activity described above. I give permission for my child(ren) to participate in said trip. In consideration for my child(ren)'s participation, I hereby release, save harmless and indemnify Blessed Sacrament, Assumption BVM, and St. Brigid Parishes, its employees, volunteers, agents and any sponsors or benefactors of said trip from any and all liability from any and all injury. I understand that my son(s)/daughter(s) will be under the supervision of the designated supervisors and chaperones on the stated dates and that all parish rules will be in effect. I understand and agree that, if my son(s)/daughter(s) violates a parish rule, he/she/they will be sent home.
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Alternate Emergency Phone Number
*
Please enter a valid phone number.
Medical Release
In case emergency medical treatment is necessary and I am not available to give consent, I authorize the adult advisor in charge to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named minor(s) under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan.
Medical Insurance Carrier
*
Policy Contract Number
*
Family Physician
*
Parent/Guardian Signature
*
Submit
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