PICNIC, CANOEING, AND PUTT-PUTT

(St. Augustine Parish, Barberton)

THURSDAY, JUNE 22, 2017

This form is due in no later than Monday, June 19.

Come join us for an afternoon picnic, canoe trip, and a round of putt-putt! We will be heading down to the Canoe Livery in
Canal Fulton from 12:30-5:00. They are located at 219 W. Cherry St. (Rt. 93), Canal Fulton, OH 44614. We will be
carpooling from St. Augustines and return there for pick up.

The entire cost of the afternoon is $10, which is due when you turn in this permission slip.

When you turn in this permission slip you MUST turn in their waver form, which is stapled to this form.

What to Bring:
Sunblock, water bottle for the canoe ride, and clothes that you dont mind getting wet (in case you fall in or
get splashed from the oar).

Please KEEP the top section as your reminder!!

Please return this section and parent signature by Monday, June 19 to Miss Jackie.

I, ________________________________, am the ________________________________ of

(Name of Parent/Guardian) (Father, Mother, etc)

_______________________________, a participant in the Canoe, Picnic, and Putt-putt trip.

(Students name)
I hereby request permission for the above named child/children to attend the St. Augustine Canoe, Picnic, and Putt-Putt trip and I consent to the
childs participation in this retreat. I understand that I must provide transportation to and from the Church for my child. I hereby assume all risks in
connection with the youth event and I further release discharge, and/or otherwise indemnity the Diocese of Cleveland, the Bishop of the Roman
Catholic Diocese of Cleveland, St. Augustine, employees and volunteers from all claims, judgments, liability by or on behalf of my child, my self and
my spouse for any injury or damage due to the childs participation in the youth event, 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/children. I understand I have
the opportunity to call Jaclyn Snyder at 330-745-1080 and ask her about the youth event.

Please fill out a current Medical Release Form if you have not done so for the 2016-2017 school year.

Childs Name _________________________________M/F?

Age ____ School _______________

Address__________________________________ City __________________

Teens Cell Phone# _______________________Home Phone#___________________________

Parents Cell/Emergency#__________________Parents E-Mail_____________________________

Signature of Parent/Guardian__________________________

Allergies _____________________________________________________________________
Please list any health problems you may have and any medications being taken at the present time. (Confidential)
____________________________________________________________________________

I am willing to chaperone if need be (cost of $10 is your responsibility for you and any extra persons). You are
welcome to bring any members of your family who want to come, excluding any family members, how many
EXTRA seats you have in your vehicle:________________________________