April 26_ Girls Retreat _ Permission Slip

HOLY NAME OF JESUS-ST. GREGORY THE GREAT PARISH

Date(s): SATURDAT, April 26, 2025 (9am - 2pm)

Event: "Capture My Heart" GIRLS RETREAT

Location: at Our Lady Queen of Angels Convent (232 East 113th St, New York, NY 10029) AND Holy Name of Jesus Church (206 W 96th St, New York, NY 10025)

Departure at 8:30am from Holy Name of Jesus - St. Gregory the Great Parish via bus - please bring your MTA card (optional). Participants may also meet directly at the Convent at 9am.

Name of minor child Participant

Address

Birthdate

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

School attending

Current grade

Parent / Guardian Full name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

MotherFatherStepparentOther

Name of primary emergency contact

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

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

Please INITIAL: I give you permission for my child to be photographed or recorded on video during the course of the Faith Formation 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

My daughter will travel with the group, departing at 8:30am from Holy Name of Jesus - St. Gregory the Great Parish via public transportation. She will bring their MTA card.My child will meet the group directly at Our Lady Queen of Angels Convent (232 East 113th St, New York, NY 10029) at 9am.

PERMISSION TO PARTICIPATE: I, (full name of parent or guardian)

grant permission for my child (child's full name)

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

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