Official Use Only Payment Method: ___________ Check Number: _____________ Date:______ Deposit:________
St. Patrick Catholic Community PERMISSION / MEDICAL RELEASE Every person who participates in the following listed events must fill out & turn in this form. Participant name(s) ___________________________________________ Teen’s cell phone ____________________________
Teen’s grade_____________
Going on trip with (friend’s name) _____ ________________________________________________ Parent contact name __________________________________________ Parent’s address ________________________________________________________________________ Parent’s cell phone _______________________ Parent’s email __________________________________ The above named person(s) is/are permitted to participate in the St. Patrick Life Teen:
Disney/Beach Trip: May 31st-June 2nd, 2017 Anaheim, CA COST= $250 I/we understand that reasonable precaution will be taken to safeguard the health and safety of the participant(s) and that the designated emergency contact person will be notified as soon as possible in case of emergency. In the event of any sickness or accident, person(s) will not hold St. Patrick Catholic Church, The Diocese of Phoenix, any volunteer, chaperone, or driver responsible. I/we authorize and consent that emergency treatment be rendered under the general or specific supervision and on the advice of any physician, dentist, or surgeon; licensed to practice in the State of Arizona or any other state. The undersigned understand(s) and agrees that any medical, dental, or hospital expense incurred shall be at their own expense. The undersigned understand(s) every effort will be made to notify the emergency contact in the event that treatment is necessary. _____________________________________________________ Parent / Guardian Signature
_____________________ Date
Insurance Carrier _______________________ Group # ________________ Do you give permission for Tylenol to be dispensed if requested by minor(s) YES - NO Please list any known allergies, health problems, or current medications:
_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ IF I/WE, CANNOT BE REACHED IN THE EVENT OF AN EMERGENCY, THE FOLLOWING PERSON(S) IS/ARE AUTHORIZED TO ACT ON MY/OUR BEHALF: Name(s) ______________________________________Phone _________________________________ Relationship to participant(s) ____________________________________________________________
the general or specific supervision and on the advice of any physician, dentist, or surgeon; licensed to practice in. the State of Arizona or any other state. The undersigned understand(s) and agrees that any medical, dental, or. hospital expense incurred shall be at their own expense. The undersigned understand(s) every ...
Page 1 of 1. NEW YORK STATE PUBLIC HIGH SCHOOL ATHLETIC ASSOCIATION. WRESTLING MINIMUM WEIGHT ASSESSMENT. PARENTAL AWARENESS FORM. The appropriate and healthful control of body weight for wrestlers has been a concern of athletes, coaches,. athletic t
Health Insurance Company Policy Number. Page 1 of 1. Parent-Permission-Form-Fillable.pdf. Parent-Permission-Form-Fillable.pdf. Open. Extract. Open with.
The District shall make no distinction between absences for UIL activities and absences for other extracurricular activities approved by the Board. A student shall be allowed in a school year a maximum of ten extracurricular absences not related to p
______ List of family members or friends that might pick her up: Please list any medical condition we should be aware of such as asthma, allergies ... ADDRESS: ...
Chaperones are asked to pay the $40 fee. _____ I cannot chaperone but would like to stay for a meal. _____ Friday supper $8.50. _____ Saturday lunch $7.00. _____ My child needs a ride with another member. Salem Youth Symphony. 503-485-2244. PO Box 11
Page 1 of 2. ESUMS HIGH SCHOOL. 130B LEEDER HILL 06517. PHONE: 203-946-5882. GUEST PERMISSION FORM FOR ATTENDING. SCHOOL DANCE. COMPLETE BOTH SIDES AND RETURN FORM TO SECRETARY-TERESA FLOWERS. Name of ESUMS High School Student (please print): ...
Mar 4, 2017 - Page 1 of 1. PSAT 8/9 Test Informational/Permission Form - Google Docs.pdf. PSAT 8/9 Test Informational/Permission Form - Google Docs.pdf.
Field Trip Permission & Parental Consent Form 2017-2018.pdf. Field Trip Permission & Parental Consent Form 2017-2018.pdf. Open. Extract. Open with. Sign In.
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the Pack 208 website and Facebook page for our scouts and families, as well as to interest ... (You can use your existing non-Gmail account to create a Google.
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RELEASE, HOLD HARMLESS AND INDEMNIFY St. Joan of Arc Church & School, the Division of Youth. & Young Adult Ministry, the Roman Catholic Archbishop of Baltimore and his successors, a Corporation Sole, and all. their affiliate organizations, and respec
CITY STATE ZIP STREET ADDRESS. LOCAL PHONE HOME PHONE CITY STATE ZIP. For transient approval, you must be in good Academic Standing (2.0 GPA) at GSU. You are only allowed to be a transientstudent at another institution for one term. FYI - Transient P
Page 1 of 5. DHE,C. ffiffiffi. Catherine E. Heiel, Director ?irt;tic1t;;y rtttr/ fttt;i1;;ji7g tl,t /'rrtlr/; $thr: publit',ti*1 tly r;.;t i;z;y::t:;ti. January 2016. Dear Parents/Guardians : The Tdap vaccine protects children from three serious dise
205 North 4th Street, Baton Rouge, LA 70821. Registration forms are due at least two weeks before all events. Registrations received after the deadline will be ...