YM Permission Slip

Youth Ministry Permission Form

Please complete this form for all offsite St. Patrick Youth Ministry events.
Teen Name:*

First NameLast Name
Teen's School Grade*
School Attending*
Youth Ministry Event Name and Date for this Permission Slip:*
Holy Fire Conference, Saturday, October 19, 2019
Medical Release
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone:*
Physician Name:*

First NameLast Name
Physician Phone*
Known Allergies:
Dietary Restrictions:
Current Medications:
Will you need assistance with your medication(s) during event?*

YesNo
Please specify the assistance you will need with your medication(s):*
Emotional/Psychological conditions/concerns:
Health Insurance Provider:*
Policy Number:*
Group Number:*
Name of Insured:*
Youth Permission and Parental Guardian Authorization
I hereby give permission for my child [Teen Name above] to participate in [Youth Ministry Event above] sponsored by Youth Ministry of St. Patrick Church [see date above].

I hereby release and indentify St. Patrick Church in Lake Forest, its staff and volunteers, Catholic Charities of Chicago, and the Catholic Bishops of Chicago, a corporation sole from any and all liability arising from claims of any kind of nature whatsoever from my child’s participation in this program.
Parent Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent Email Address*
example@example.com
Parent Phone Number*
Teen Phone Number*
Parent Signature*

Clear
Youth Media Release

By not selecting the box(s) below you are not giving your permission for that item(s).
I hereby give St. Patrick Catholic Church or any of its affiliates permission to:

Take, copyright and/or publish photographs, videos, audio recordings, or interviews of my child.Interview my child about his or her experience and publish the interview in whole or in part without the right to review.Send text messages to my child for church related events.
I understand these photographs, videos, audio recordings, or interviews may be used for publication and/or for other public affairs purposes, including publications, advertisements, displays and placement on the St. Patrick Catholic Church’s website, as determined by St. Patrick Catholic Church.

I hereby waive all rights that I may have to any claims for payment or royalties in connection with the use of these photographs, videos, audio recordings, or interviews, and agree that these photographs, videos, audio recordings, or interviews shall at all times be the property of St. Patrick Catholic Church.

I hereby release St. Patrick Catholic Church or any of its affiliates, employees or agents from all liability, including any claims for libel or invasion of privacy, directly or indirectly connected with, arising out of or resulting from the taking and authorized use of these photographs, videos, audio recordings, or interviews.
Teen Name:*

First NameLast Name
Parent Name*

First NameLast Name
Parent Signature*

Clear
Should be Empty:

Youth Ministry Permission Form

Medical Release

Youth Permission and Parental Guardian Authorization

Youth Media Release