Permission Slip & Hold Harmless Agreement

Permission Slip & Hold Harmless Agreement

St. Joseph the Worker Parish, Williamsport, PA
You only need to complete this form once for the 2024-2025 School Year (September 2024-July 2025).

Dear Parents/Guardians:This Permission Slip & Hold Harmless Agreement is required for any youth who is not accompanied by a parent/guardian, or responsible adult, at any parish event held off-campus. (EXCEPTION: Due to the nature of the event, all participants in the Nerf War are required to complete this Permission Slip & Hold Harmless Agreement even if their parents are attending.) If a parent or legal guardian attends the off-campus event with their child, then the Permission Slip & Hold Harmless Agreement is not required to be on file for that event.

Please note that you will still need to RSVP for each event, this form is simply granting your permission for your child to participate in this year's events.

At all events, please be sure to sign your youth in and out at drop-off and pick-up!

Thank you for your witness to Christ in the life of your child! God bless!
Name of Participant*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
If you have more than one child participating, please list them below:
Participant 2: Name

First NameLast Name
Participant 2: Date of Birth

MonthDayYear
Date
Participant 3: Name

First NameLast Name
Participant 3: Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name*

First NameLast Name
Cell phone of Father*

Area CodePhone Number
Mother's Name*

First NameLast Name
Cell phone of Mother*

Area CodePhone Number
Medical Information
Family Physician
Name
Phone Number of Physician

Area CodePhone Number
Allergies
Please include food, non-food allergies and medication allergies
Current Medications
Please include all.
Medical History
Anything we should be aware of
Emergency Contact other than Mother or Father

First NameLast Name
Phone Number

Area CodePhone Number
I*

First NameLast Name
request that St. Joseph the Worker Parish allow my child(ren) to partcipcate in the above Youth/Parish Event(s). I give permission to use my child(ren)'s name, picture, and voice in the parish bulletin, Youth Events newsletters and fliers, as well as the parish website and social media pages.
Hold Harmless Agreement

for event(s) listed above
I (name of legal guardian)*

First NameLast Name
agree to protect, idemnify, save, and keep harmless, St. Joseph the Worker Parish, the Roman Catholic Diocese of Scranton, and Gallagher Bassett Insurance Services against and from any and all loss, cost, damage, or expense, arising out of, or from, any person or property whomsever and whatsoever; and will protect, indemnify, save and keep harmelss the above mentioned parties from any and all claims, costs, or expense arising out of any accident or other occurrence on or about said premises or in conjunction with any activity sponsored by St. Joseph the Worker Parish or the Roman Catholic Diocese of Scranton, causing injury to any person or property whomsoever or whatsover; and will protect indemnify, save and keep harmless the above mentioned parties from any and all claims, costs, or expnses arising out of any failure of any contractor in any respect to comply with and perform all requirements and provisions agreed-to and required by any law or ordinance related to the aforementioned premises or activites. I also hereby confirm that I have medical insurance or self-insured coverage which will be the sole provider of medical benefits and payments in the event of injury or illness arising out of any activity sponsored by St. Joseph the Worker Parish or the Roman Catholic Diocese of Scranton.
Signature of Legal Guardian*

Clear
Date

MonthDayYear
Date
Should be Empty:

Permission Slip & Hold Harmless Agreement

Medical Information

Hold Harmless Agreement