Roman Catholic Area Faith Community of
St. Anastasia & St. Boniface
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Roman Catholic Area Faith Community of
St. Anastasia & St. Boniface
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YOUTH ACTIVITY PERMISSION FORMSt. Anastasia- St. Boniface Catholic Faith Community Alex Barraza or Mary Lohaus: 234-6129 Youth Ministry/ RE Office St. Anastasia - Hutchinson Karen Maiers 833-6020 – St. Boniface - Stewart YOUTH ACTIVITY __________________________________________________________________ CHILD’S NAME ______________________________________________________________________ ADDRESS _________________________________________ PHONE____________________________ CITY_____________________________ STATE_______________ ZIP CODE___________________ SCHOOL _______________________________ GRADE __________ BIRTH DATE ______________
PARENT / GUARDIAN’S NAME ________________________________________________________ CELL PHONE _____________________________ OTHER NO.________________________________
PERSON(S) OTHER THAN PARENT) TO NOTIFY IN CASE OF EMERGENCY: NAME _________________________________________ RELATIONSHIP _________________________ PHONE __________________________________ CELL PHONE __________________________________
Medical Insurance is not required in order for youth to attend event. Information is only requested in the regrettable event of an accident .MEDICAL INSURANCE PROVIDER:_____________________________________________________ POLICY NO.__________________________________________________________________________ PHONE NO.___________________________________________________________________________ I, the parent (guardian) of the above named child, hereby, give my permission for his/her participation in the youth activities named above. I agree to direct my child to cooperate and conform with directions and instruction of St. Anastasia- St. Boniface Catholic Faith Community personnel or volunteers responsible for such youth activities.I agree that in the event my child is injured as a result of his/her participation in the above named youth activities, including transportation to and from these activities, recourse for the payment of any resulting hospital, medical, or related costs and expenses will first be had against any accident, hospital, or medical insurance, or any available benefit plan of mine or of my spouse. I understand that it is my responsibility to pay any co-pays to any medical institution or/and any balance not cover by any of the above mentioned. I am not aware of any medical condition of my child which would render it inappropriate for him/her to participate in any such activity. I, hereby, give permission to the physician selected by the youth activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician.
PARENT / GUARDIAN’S SIGNATURE ____________________________________ DATE _________ Would you like to volunteer for this event: Yes___________ No____________________ |