Roller Skating-Middle School Event 2026

Roller Skating Event 2026 Middle School Youth Ministry

Saturday, November 7, 2026 (Details below)
Student Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade:
Gender
Address

Street Address

Street Address Line 2

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Postal / Zip Code
Family Email
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Parent/Guardian Name

First NameLast Name
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Teen Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Medical and Permission Form

I grant permission for the administration of First Aid to my youth by the people in charge of the event, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery deemed necessary for my child.
Can we give your child over-the-counter basic medicine (Tylenol, Tums, etc) ?
Allergic to any medications?
If yes, please explain:
Please list any other allergies (food, insect bites, etc.):
Medications participant is currently taking:
Authorized physician
Physician Phone Number

Area CodePhone Number
Parent/Guardian Signature
In case of emergency, we will contact the parent/guardian named above first. We ask that you provide an alternate contact just in case.
Alternate Emergency contact:

First NameLast Name
Emergency contact phone number:

Area CodePhone Number
I give St. Margaret Mary permission for my youth’s participation in videos or photographs, which may be used for future promotional efforts, including the Diocese of Rockford website and St. Margaret Mary website and/or social media.
Youth Signature
Parent/Guardian Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Comments:
Roller Skating-Middle School Event

Payment & Details

Date: Saturday, November 7, 2026  Time: 1-4 PM Who: 5th-8th Graders

Where:  Xtreme Wheels 691 S. Virginia Road in Crystal Lake

Cost: $15 without skates     $10 with your own skates

(Cash or Checks: Payable to St. Margaret Mary Church)

Food: Bring additional money for snacks

Transportation: We are asking that middle schoolers be dropped off at Xtreme Wheels at 1 PM and picked up by 4 PM. Thank you.
Should be Empty:

Roller Skating Event 2026 Middle School Youth Ministry

Medical and Permission Form