76ers outing-

Diocese of Wilmington – Form B ST MARY MAGDALEN Consent and Release
76ers Game Outing
February 9th
6:30pm-10:30pm
We encourage all of our SMM basketball athletes in
grades 3-12 to attend, but families with children up
to grade 12 are welcome to join us as well.
My child (please print ful name) _______________________________ has my permission to attend the St Mary Magdalen 76ers game outing on February 9th. I understand that they wil be traveling via bus to and from the game. We wil depart SMM at 6:30pm and return to SMM at roughly 10:30pm. I understand that the cost is $20 per child, which includes transportation and their ticket. I hereby give my permission for my child to attend said event and I understand that my child wil be chaperoned by responsible cleared adults. I understand that CYM, the Diocese of Wilmington and its staff are committed to providing fun, safe, educational experiences and that CYM events are conducted in smoke-, alcohol-, and drug-free environments. In light of this, and to help ensure the safety of al concerned, I understand that if my child is in possession of drugs, alcohol, or tobacco products, engages in il egal, immoral, or offensive behaviors, or refuses to fol ow the directions given by CYM staff or volunteers while participating in this activity, I wil be contacted immediately to pick up my child. As parent/guardian, I understand that promotional pictures (individual and group) wil be taken during this event. I give permission for my son’s/ daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, etc.) in highlighting the event. By my signing this, I release CYM Staff, The Office for Catholic Youth Ministry, additional chaperons, and the Diocese of Wilmington from any and al liabilities and waive al claims against them. I also give my permission for the event coordinator and other qualified cleared adults to obtain proper medical treatment for my child should it become necessary.
Grade_____________School_________________Insurance Carrier/Policy Number____________________________________________ Insurance company address_______________________________________________ Insurance company phone number__________________________________________ Prescription meds taken regularly___________________________________________ Other medical issues we should be aware of__________________________________ Emergency Contact Name/Number__________________________________________ Electronic/mobile communication affords the CYM staff or event coordinators the best means of providing reminders and updates to participants. Please provide an email address and/or cell phone number for such communication purposes. Providing information here limits its use to this particular activity or event. E-mail address _____________________________________ If necessary, the group leader is permitted to administer the following over the counter medications to my child:__ Advil __ Tylenol __ Motrin __ Aleve __ Claritin/Zyrtec __ Benadryl __ Robitussin (cough syrup)__ Halls (cough drops) __ Other (please specify) __________________________ Payment: ($20 per child): please check one! Signature of Parent/Guardian:_________________________________Date_________ I am willing to chaperoneI am a coach of one of the SMM Basketball Teams

Source: http://smmchurch.org/documents/76ers%20Outing.pdf