St. Anthonys of Ely, MN at 231 E. Camp St., Ely, MN 55731 US - Permission Slip

 

Your son/daughter, ward, _________________________________ is eligible to participate in a school/parish sponsored activity that requires permission. This activity will take place under the guidance and supervision of employees/volunteers from St. Anthony and St. Pius X Churches (parish/school).

 

A brief description of the activity is as follows:

 

I consent to the participation of my child/ward in the above named activity. In consideration for my child/ward's participation, I agree to reimburse and indemnify the above named parish/school (understood to include the Diocese of Duluth) for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found liable for the injuries sustained by child/ward, this paragraph will not apply.

 

I certify that I have an understanding of this agreement and the risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.

 

                                                                                                                                                        

Parent/Legal Guardian Signature                             Date

                                                                                                                                                        

Address                                                                 Home Phone                                 Work Phone

 

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child/ward to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

 

                                                                                                                                                        

Name and relationship                                            Phone Number

                                                                                                                                                        

Medical Insurance Company                                   Policy Number

 

Please furnish medical information about your child/ward which may be pertinent to his or her participation in the above identified activity:                                                                                                                               
 

_                                                                                                                                                       .

 

 

Please keep this form on file at the parish or school for four years.