Winter Stretch: Parent Guardian Consent Form and Indemnity Agreement

Student/Participant Name: ______Birthdate: ______

Sex: Grade Level (7-12): ______

Meeting Place: Church of St. Gerard (9600 Regent Ave. N. Brooklyn Park, MN 55443). We will carpool to Feed My Starving Children, return to St. Gerard for lunch, and carpool to Grand Slam in Coon Rapids Students must be picked up from St. Gerard at 4:30pm.

Date of Event: Monday, February 19th 2018

Time of Event: 8:15am-4:30pm

Individual(s) In Charge/Contact Person: Alannah Moran- Youth Ministry Assistant

Transportation being used: Carpool (We will need parent volunteer drivers for both the morning and afternoon shifts)

Cost: $15 per student. Snacks and arcade tokens can also be purchased at the concession stand.

Special Instructions for this trip: PERMISSION FORMS AND PAYMENT DUE BY February 15th

Mother ______Cell # ______

Father ______Cell # ______

Home Address City State Zip______

(Main Source of Communication) Family E-Mail______

*EMERGENCY CONTACT IF PARENTS/GUARDIANS CANNOT BE REACHED

Name Phone-Home and/or Cell Work

______/______

Doctor # Hospital

I, , grant permission for

(Parent/Guardian’s Name – please print) (Child’s Name – please print)

to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to indemnify the Church of St. Gerard, St. Vincent de Paul and the Archdiocese of St. Paul/Mpls from any claims or lawsuits brought against the Church of St. Gerard, St. Vincent de Paul and the Archdiocese of St. Paul/Mpls, by myself, my child, or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney’s fees or expenses incurred by the Church of St. Gerard, St. Vincent de Paul, and the Archdiocese in defense of such a claim/lawsuit. Permission is also granted to St. Vincent de Paul to use video/photo(s) of my child(ren) for use in promoting St. Vincent de Paul. I agree that St. Vincent de Paul may use such photographs/videos in publications related to programs with the knowledge that these publications may be posted electronically on the St. Vincent de Paul webpage and on the St. Vincent de Paul Facebook page which is accessible only to members of the page. Last names of children will not be published. I/We agree to release, indemnify and defend St. Vincent de Paul for any claims related to the use of my child’s photos as described above.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to call 911 and transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. If I/we cannot be reached, please call the above named person/s.

Please list any health concerns or special circumstances pertaining to your child. Use reverse side if more space is needed:

As parent/guardian, I agree to all of the above stated considerations and conditions.

(Signature) (Date)

I am interested in helping out as a chaperone for this event: YES NO Call me if you’re desperate!