ARCHDIOCESAN YOUTH DAY
November 16, 2019
Field Trip Parental Consent Form
& Indemnity Agreement
Student/Participant Name: {name}
Parish/School: St. Bartholomew Catholic Faith Community City: Wayzata
Date of Birth: {studentsDate} Sex: {studentsSex}
Parent/Guardian Name: {name9}
Home Address: {studentsHome}
Phone: {phoneNumber10}
Date of Event: November 16, 2019
Type of Field Trip: Archdiocesan Youth Day
Destination: St. Thomas Academy, Mendota Heights
Individuals/Teachers in Charge: Ana Gagliardi
Time of Departure: 1:30 PM Time of Return: 10:30 PM
Mode of Transportation: Cars
I, {name9}, grant permission for {name} to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to hold parish/school and Archdiocese harmless from any and all claims resulting in my child’s participation in this event. I further agree to indemnify the parish/school and the Archdiocese of St. Paul & Minneapolis from any claims or law suits brought against the parish/school /Archdiocese of St. Paul & Minneapolis by myself, my child or others, that arises out of any behavior by my child at the event/activity described above and for any harm my child incurs by reason of their participation in the above described event. I also agree to pay reasonable attorney’s fees or expenses incurred by the parish/school and the Archdiocese in defense of such a claim/suit.
Use of Image: I grant permission to the parish/school and Archdiocese of Saint Paul and Minneapolis to use and publish for advertising, commercial or publicity purposes, the name and likeness of my child, or for any other lawful purpose whatsoever, including photographic portraits, pictures, reproductions, or audio or video recordings, made through any medium, including electronic media, and the undersigned parent/guardian does hereby release and the Archdiocese of Saint Paul and Minneapolis or anyone authorized by the Archdiocese of Saint Paul and Minneapolis with such use. This authorization and consent permits such use to associate my child’s name with the likeness for such purposes provided such use is consistent with the acceptable use policy for electronic communications and other policies.
Emergency Medical Treatment: In the event of an emergency, I give permission to transport my child to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of any emergency, if you are unable to reach me at the above numbers, contact {secondaryEmergency27} at {phoneNumber}.
Optional Medical Information:
Medications my child is taking at present: {medicationsMy}
Family Health Plan carrier number: {familyHealth}
Family Doctor: {familyDoctors} Doctor's Phone Number: {doctorsPhone}