HNJ-SGG Youth Group Permission Slip 2024-2025

Holy Name of Jesus - St. Gregory the Great Parish: Youth Group

Minor Child (Participant) Information

Name of minor child (Participant)*

Address*

Birthdate*

Date

Child - Phone Number*

Child - Email*

example@example.com

School attending

Current grade

Parent/Guardian 1 Information

Parent/Guardian 1 - Full Name*

Parent/Guardian 1 - Phone Number*

Parent/Guardian 1 - Email*

example@example.com

Parent/Guardian 1 - Relation to Child*

MotherFatherStepparentOther

Parent/Guardian 2 Information

Parent/Guardian 2 - Full Name

Parent/Guardian 2 - Phone Number

Parent/Guardian 2 - Email

example@example.com

Parent/Guardian 2 - Relation to Child

MotherFatherStepparentOther

Name of primary emergency contact*

Mobile Phone of Primary Contact*

Are there any medical, physical or cognitive conditions that the youth group team needs to be aware of, such as allergies (including food allergies), seizures, physical limitations, etc.?*

YesNo

If yes, please describe conditions and any appropriate guidelines for our volunteers. We also recommend speaking directly to the group coordinators.

Please INITIAL all appropriate items:

I give you permission to contact my child via FLOCKNOTE text (Safe Environment compliant)

I give you permission to contact my child via FLOCKNOTE email (Safe Environment compliant)

I give you permission for my child to be photographed or recorded on video during the course of youth ministry events. By initialing I provide consent for their image to be used in either print, electronic or video form for the promotional purpose of future activities.

Parent/Guardian*

First NameLast Name

grant permission for my child,

Child*

First NameLast Name

to participate in the Holy Name of Jesus-St. Gregory the Great Parish

Hold Harmless Agreement

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant") I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend Holy Name of Jesus-St. Gregory the Great Parish, its officers, directors, employees and agents, and the Archdiocese of New York, its employees and agents, chaperones or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of New York, its employees and agents and chaperones, or representative associated with the event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.

Signature of legal guardian*

Date*

Date

Permission to Participate