Permission Slip (Parents keep this part)

OLPH CYO: Caroling to shut-ins – 1:30 p.m. – need drivers &

Christmas Party, Sat., Dec. 10 – 743 Oak Tree Road – 5 – 8:30 p.m. (provide your own transportation)

Bring a generic $10 gift wrapped for the gift exchange

Youth Board – bring desserts, Boys-2 2ltr drinks, girls - snacks

Dress in Christmas color or attire

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Waiver of Responsibility

Our Lady Perpetual Help, Belle Chasse

Catholic Youth Organization

In consideration of the benefits to be derived, and in view of the fact that the CYO is a youth organization, membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety and well being of my child(s)/ward(s), namely:______on the activity named below, I agree to their participation and waive all claims against the leaders of the trip, agents, and representatives of the CYO, the sponsor, Our Lady of Perpetual Help Church and Archdiocese of New Orleans.

I understand that if a serious disciplinary problem exist with my child I will be notified and it is my responsibility to pick them up, or pay the expense of their return (where applicable).

In the event of an emergency, the trip leader of the activity named below has my permission to obtain medical treatment for my child at the nearest hospital or doctor, at my expense, if our own doctor is not readily available, and as restricted on the Emergency Data Sheet on file church office.

______

(Signature of parent or guardian and date)

ACTIVITY: Christmas Party-December 10, 2016

EMERGENCY INFORMATION (In addition to Personal Health and Medical Record.)

During the activity listed above, I can be contacted at the following phone and will accept long distance calls.

(_____) ______; (_____) ______

This child is highly allergic or sensitive to ______

What, if any, medication is this child taking?______

Use the back of this form for additional information and for explanation of any other problems the activity leader should be aware of.

Date of the latest or last tetanus shot/booster______.

I (do or do not) grant permission for non-perscription medication (such as aspirin, throat lozenges, couth

(circle one)

syrup to be given to my child, if deemed appropriate. ______

Parent signature)

Medical Insurance Information: Company :______

Policy no. ______(Control No. if group policy)______.