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Immaculate Heart of Mary Church Permission Slip/Medical Release
You are representing the Archdiocese of Indianapolis and Immaculate Heart of Mary Church during our outing. We expect that you will display a mature and responsible behavior, which for many years has been the trademark of Catholic youth. Please complete entire form, youth and parent.
Expectations are:
- All participants are expected to arrive on time.
- All participants are expected to demonstrate courtesy and respect.
- Dress should reflect the value of modesty.
- Possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug by an individual is not permitted.
- Smoking is not permitted.
- Any prescription drugs need to be given to an adult for storage and distribution.
I understand and agree to this behavior code. I also understand and agree that my parents or guardians will be notified at the time of the infraction requiring my dismissal. My parents or guardian will be responsible for my removal from the premises.
Youth Name:__________________________________________Signature:_______________________
My child ___________________________________ will participate in the______________________
I hereby release and indemnify the Youth Minister, staff, volunteers and the Archdiocese of Indianapolis from any and all liability from claims of any kind or nature whatsoever from my child’s participation in this event.
I understand that I will be notified at the time of any major infraction by my child, which will result in his/her dismissal from the trip.
I grant the permission of First Aid to be given to my child by the people in charge of the event, and those transporting any child to and from the service projects as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult start to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery, if deemed necessary for my child.
Health Ins. policy in the name of:_________________________________________________________________
Insurance Company & Number:_______________________________________________________________
Authorized Physician:________________________Phone Number:____________________________________
Parent Name (s):____________________________Home Phone Number:_______________________________
Cell Number:_____________________Emergency Number:_________________________________________
I give permission for my child's photograph to appear on IHM's bulletin boards and web site ____Yes ____No
Parent Signature:_____________________________________Date:________________________________
YES - I WOULD LOVE TO CHAPERONE________________________________________________________ |
