Permission Slip/Emergency Medical Form
I, ______, give my permission for my child______,
(Name of Parent/Guardian) (Student’s Name)
to attend the activity (activities) checked below.
In consideration of the above child being allowed to participate in the above field trip, on behalf of my child, my spouse and myself, I hereby assume all the risks in connection with the field trip and I further release, discharge, and/or otherwise indemnify the Diocese of Cleveland, the Bishop of the Roman Catholic Diocese, St. Vincent Elementary School, St. Vincent de Paul Church, employees and volunteers from all claims, judgments, liability by or behalf of my child, myself, and my In the event of an accident or injury, or damage due to the child’s participation in the field trip including all risks connected therewith, whether foreseen or unforeseen. Furthermore, I acknowledge that it is my responsibility to provide adequate health insurance for my child. By signing this form, I declare that I am the legal parent/guardian of the minor child listed above and I am authorized to grant such permission.
I fully understand what is involved in the above field trip/event, and I understand that I have had the opportunity to call the teacher or adult in charge and ask for additional information if necessary.
Signature: ______Date: ______
Please check events:
Middle School and High School Youth Ministry
November and December 2015 Calendar
November
_____3 - Crafts for the Nursing Home
Scullen Room right after school. Come helps us make a treat for our Catholic friends at the Merriman and Hickory Ridge. Have parents pick you up at 4:30 pm. Can’t make until later, no problem… come when you can. I will have snacks to share.
_____6 - Cav’s Game
The Cav’s are playing the 76’s and the game starts at 7:30. Van leaves the parking lot at 6:00 so you may want to come a few minutes earlier. Twenty five students will get to greet the Cavs at ½ time as they come back onto the court! Only 14 tickets remain. Tickets are $39 each and they need to be made out to Mrs. Dies
_____13 - Giving Tree Set-Up
Meet Mrs. Dies in the church after school and help her set-up the Giving Tree. Have parents pick you up when we are done… approx. 4:30. Have practice? No problem, stay as long as you can!
_____19- Christ Child Boutique Help or Saint Vincent de Paul Craft Show
Help Christ Child load the truck! Meet at St. Vincent at 3:30, travel to Cuyahoga Falls, load the truck and return by 5:30. Only 4 are needed. Mr. Downey is in charge. He will need help on Friday, November 20th from 6:00 to 9:00 and on Saturday from 8:00 – 4:00… in 2 hour intervals. Sign-up sheets will be provided by Mr. Downey!
_____ Christ Child set-up
_____ Craft Show set-up and show (Be sure to sign up on Mr. Downey’s sheets!)
_____25 –Salvation Army – Ringing of the Bells
Yes, I know it is the day before Thanksgiving, but what better way to help than to ring bells at Acme #1 on West Market Street by the railroad crossing from 4:00 to 9:00? Please let me know which shift you are able to work… _____4:00 – 6:30 or
_____ 6:30 - 9:00. Or both!
_____30 – Middle School and High School Regular Meeting
Let’s plan December and January events! And yes, I know some of you have the day off, so…bring your ideas to share. ALL ARE WELCOMED… EVEN IF YOU HAVE NEVER COME BEFORE!
Open gym from 5:00 – 6:30. I’ll provide the gym; you provide board games, movies, etc. A short meeting will take place sometime during this period. Be sure to bring ideas for service projects, Christmas ideas, etc. We can even have pizza after Mass.
December
_____1- Crafts for the Nursing Home
Scullen Room from 3:00 – 4:30. Come helps us make a treat for our Catholic friends at the Merriman and Hickory Ridge. Have parents pick you up at 4:30 pm. Can’t make it right at 3:00? No problem; come when you can!
_____8- Giving Tree Wrap-Up and Feast of the Immaculate Conception
Join us in the rectory from 3:00 – 5:00 as we organize the gifts from the Giving Tree. We need to get them ready for distribution. Come when you can and stay as long as you can. I’ll bring the hot chocolate…you bring the Christmas music and movies. If you have not gone to Mass already, stay and we will go together at 5:30.
Ellen Dies
Youth Ministry
St. Vincent: (330)535-3135 ext. 101
See emergency information on back.
Emergency Information
Name of student: ______Age: ______
Name of parent or guardian: ______
Address: ______
Phone Number: ______Cell Phone: ______
Emergency Contact Name and Number if parent/guardian cannot be reached:
______
List any medications: ______
List any Allergies: ______
List any emergency instructions: ______
Please fill in either Part I (consent) or Part II (refusal of consent)
Part I – To Grant Consent for Emergency Medical Treatment:
In the event that reasonable attempts to contact me have been unsuccessful, I hereby give
my consent for emergency medical treatment to be administered to my child.
Signature of parent/guardian: ______Date: ______
Part II – To Refuse Consent for Emergency Medical Treatment:
I do not give my consent for emergency medical treatment of my child.
Signature of parent/ guardian: ______Date: ______
Please call Ellen Dies for questions or for additional information
St. Vincent – (330)535-3135 ext. 101; Home – 330-864-5484