St.

Leo Youth Ministry

Life Teen & Edge Programs

EVENT: Hiking at Hanging Rock State Park

DATE(S): 9-15-2012
ACTIVITIES: Hiking, Travelling by private vehicles driven by chaperones
Supervisor: Jane Kane
NAME OF YOUTH_________________________________________________ DATE OF BIRTH_______________
ADDRESS_____________________________________________________________________________________
street
city
state
zip
SCHOOL______________________________________________________________GRADE_________________
PARENT/GUARDIAN____________________________________________________________________________
name/relationship
home phone
work phone
cell phone
IF UNABLE TO CONTACT PARENTS PLEASE NOTIFY:
_____________________________________________________________________________________________
name/relationship
home phone
other phone
I, the parent or guardian of the above named minor child, hereby give my permission for his or her participation in the youth
activity named above. If transportation is necessary, I consent to such transportation based upon the parish and/or Youth
Leader providing the transportation.
I understand that all reasonable supervision will be exercised to provide for the general well-being of my child. I hereby release
the Diocese of Charlotte, St. Leo Church, all church staff and volunteers from any and all claims, loss, damage, expense, or
liabilities arising out of or from any accident or other occurrence causing injury to any person or property during this activity,
except as a result of gross negligence.
I agree to direct my child to cooperate and conform with directions and instructions of the parish or Diocesan personnel
responsible for youth activities.
I am not aware of any medical condition of my child which would render it inappropriate for him or her to participate in any
such activity.
Please list any allergies, medications currently being taken by, or medical history of participant that might be important in an
emergency situation.

ALLERGIES: __________________________________________________________________________
MEDICATION: _______________________________________________________________________
Insurance Carrier_______________________Policy Number___________________________________
SPECIAL DIET: __________________________________________ _____________________________
OTHER: _____________________________________________________________________________
ANY SPECIAL NOTES OR INSTRUCTIONS: ________________________________________________
PARENT/GUARDIAN SIGNATURE________________________________________________________