Form and payment due no later than September 18 St.

Andrew Church Archdiocese of San Francisco $25 for the Ticket and Bus Fair Parental Permission Form Activity The On Fire event will be held at Six Flags Discovery Kingdom September 21. It will be a faith filled experience with other parishes around the Nor Cal area. Food will be provided and Chaperones will help accompany the youth! We will be taking a school bus from Mater Dolorosa at 7:10AM and we will be coming back from Six Flags at 10:20PM. ____________________________________ Birth date ______________________

Student's Name

Address ____________________________________________________________________________ Parent/Guardian's Name _______________________________________________________________ Address ____________________________________________________________________________ Home Phone: _____________________________Work Phone: ______________________________ Person to notify in an emergency if parent is not available: Name _______________________________________________________ Relationship to student________________________________ Phone __________________________ The following person (if not the parent) will pick my teen up on Saturday evening. Name: _____________________________________________ I, the parent (guardian) of the above named student, hereby give my permission for his/her participation in the activity named above. I agree to direct my student to cooperate and conform with the directions and instructions of the parish, school, or Archdiocesan personnel responsible for the activity. I agree that in the event my student is injured as a result of his/her participation in the above named activity, including transportation to and from the activity, whether or not caused by the negligence (active or passive) of the parish/school or Archdiocesan youth activities program, or any of its agents or employees, recourse for the payment of any resulting hospital, medical or related costs and expenses will first be had against any accident, hospital or medical insurance or any available benefit plan of mine or my spouse. Except as noted below, I am not aware of any medical condition of my student which would render it inappropriate for him/her to participate in the above activity. I hereby give permission to the physician selected by the youth activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician. Parent/Guardian's Signature __________________________________Date ______________________ Other Parent/Guardian Signature ______________________________ Date _____________________