GIRLS DAY

(St. Augustine Parish, Barberton)

MONDAY, AUGUST 21, 2017

This form is due in no later than Thursday, August 17.

We will be having a fun summer day just for the girls from 11:30-3:30 at Jennifer Sebes home:
5464 Taylor Rd, Norton, OH 44203. All girls 6-12 grade are welcome to join us! Lunch will be
provided.

What to Bring:
Yourself, sunblock, bathing suit (modest), and a towel.

Please KEEP the top section as your reminder!!

Please return this section and parent signature by Thursday, August 17 to Miss Jackie.

I, ________________________________, am the ________________________________ of

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

_______________________________, a participant in the Girls Day.

(Students name)
I hereby request permission for the above named child/children to attend the St. Augustine Girls Day and I consent to the childs participation in this
event. I understand that I must provide transportation to and from the Sebe residence 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)

____________________________________________________________________________