Parental/guardian Permission Form And Release - Travel Form And Medical Matters printable pdf download

DIOCESE OF ALLENTOWN

PARENTAL/GUARDIAN PERMISSION FORM & RELEASE

TRAVEL FORM

Participant’s name:_____________________________________________________________

Birth date:______________________________________________Sex:___________________

Parent/Guardian’s name(s):_______________________________________________________

Home phone:____________________________ Alternative phone:_______________________

I (we), _____________________ grant permission for my (our) child, _____________________

(Parent or guardian’s name(s))

(Child’s name)

to participate in this parish/school program. This activity will take place under the guidance and

direction of parish/school employees and/or volunteers from ____________________________.

(Name of parish/school)

My (Our) child understands and agrees to abide by all rules and regulations established by the

parish/school.

As parent(s) and/or legal guardian(s), I (we) remain legally responsible for any personal actions

taken by my (our) child.

In consideration for my (our) child’s participation, I (we) and my (our) child, agree and

understand that we assume the risks inherent in the program, and with full knowledge of the

risks, we, and our heirs, successors and assigns, agree to release and to hold harmless and defend

the Diocese of Allentown, Bishop John O. Barres, D.D., S.T.D., J.C.L., and all of their

employees and representatives from claims from or related to my (our) child’s participation, or in

connection with any illness or injury (including death) or cost of medical treatment in connection

therewith, and I (we) agree to compensate the Diocese for reasonable attorney’s fees and

expenses incurred by the Diocese in any action brought against the Diocese as a result of such

injury or damage, unless such claim arises from the negligence of the Diocese.

We have read carefully this entire (pages 1 and 2) Parental/Guardian Permission Form & Release

and agree to its terms and intend to be bound hereby.

Participant’s signature: _____________________________ Date: ________________________

Parent/Guardian signature: __________________________ Date: ________________________

Event Description:

Date/Time:

Location:

Transportation Information:

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Parental/guardian Permission Form And Release - Travel Form And Medical Matters