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ARCHDIOCESE OF BALTIMORE
DIVISION OF YOUTH & YOUNG ADULT MINISTRY
PERMISSION FORM AND RELEASE
Youth Name: Home Phone:________________ Parent Name: Work Phone: __________________ Other number where Parent can be reached: ______________________________________________________ Address_________________________________________________ City/State/Zip ______________________
Grade_____________ ____ Date of Birth:_____________________________ Male Female (please circle) In consideration of the wholesome recreational and learning experience in which my son/ daughter will participate, I as parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to accompany the youth ministry group of Holy Family Catholic Community to:
Wash for Life-Car Wash- Oct 6, 2012-LDS-9am-1pm
In consideration of the opportunity for my son/daughter to participate in the Program, I agree to release and hold harmless
and indemnify Holy Family Catholic Community the Division of Youth & Young Adult Ministry, the Roman Catholic
Bishop of Baltimore and his successors, a Corporate Sole, and all their agents, servants and employees from any liability,
claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with
or arising out of my son/daughter’s participation in the Program.
I hereby grant permission to any staff person to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached.
I am covered by hospitalization and medical insurance under policy #_______________
issued by _____________________________________
I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for
I hereby grant permission to any staff person to provide the following over-the-counter drugs to my
son/daughter if requested by my son/daughter (Check all that apply:)
ADD any other medical information concerning medication, allergies, illness, etc. _________________________________________________________________________________________ ADD any dietary restrictions:__________________________________________________________________ Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Division of Youth and Young Adult Ministry or the Archdiocese of Baltimore. (Participants would not be identified, however, without specific written consent.) Parents/guardians who do not wish their child (ren) to be photographed or filmed should so notify the Division in writing. Please note that the Division has no control over the use of photographs or film taken be media that may be covering the event in which your child (ren) participate(s). Parent/Guardian Signature ____________________________________________ Date ___________________ Parent/Guardian Signature ____________________________________________ Date ___________________
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