PARENTAL/GUARDIAN CONSENT FORM AND INDEMNITY AGREEMENT

Participant’s name:__________________________________________________________

Birthdate:___________________________________________Sex:__________Grade____

Parent/Guardian’s name:_____________________________________________________

Home address:______________________________________________________________

Home phone:_______________________________ Cell phone:______________________

Date/Type of event: _________________________________________________________

Destination: _______________________________________________________________

Individual(s) in charge: Bo Schmidt and/ or Nancy Hochschild______________________

Estimated time of departure and return: ________________________________________

Mode of transportation to & from event: bus_____________________________________

Student cost if applicable: ____________________________________________________

ADULTS NEEDED!!!

Checking below indicates you will be in attendance at the event at no cost to you.

_____I will be a chaperone _____ I can’t help this time

I, ________________________________________________________________, grant permission for

(parent or guardian’s name)

my child, ________________________________________, 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 parish/school and the Archdiocese of St. Paul/Minneapolis from any claims or law suits brought against the parish/school/Archdiocese of St. Paul/Minneapolis 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 parish/school and Archdiocese in defense of such a claim/law suit.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

_______________________________________________Phone:______________________________

(name)

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

___________________________________________________ _____________________

(signature) (date)

Optional Medical Information:

Medication my child is taking at present:___________________________________________________________

Family Health Plan carrier number:_______________________________________________________________

Family Doctor:__________________________________________Phone:________________________________