Parent/Guardian Permission Form for Field Trips

Dear Parent or Legal Guardian:

Your son/daughter is eligible to participate in a parish sponsored activity requiring transportation to a location away from the parish building.  This activity will take place under the guidance and supervision of authorized personnel from St. Joseph Catholic Church in Howell, MI.  A brief description of the activity follows:

Name of the Event :Operation Combat Zone                                            

Destination: St. Joes and Howell Area

Date and Time of Departure: Sat. March 6 9:30-9:30pm

Date and Anticipated

Designated Supervisor of Activity: Nancy Duey, Coordinator of Youth Ministry

Student Cost:  $20

Emergency Phone Number:  517-518-1222

If you would like your child to participate in this event, please complete, sign, and return the following statement of consent and acknowledgment.  As parent or legal guardian, you remain responsible for any legal responsibility, which may result from actions taken by the named student.  This section is for your information.

PERMISSION FORM FOR FIELD TRIPS

Parents: There are 2 places your signature is required on this permission slip.  Please be sure you sign both of them!!!!

I hereby consent to participation by my son/daughter, ________________________________________ in going to St. Joseph One Day Retreat, March 6^th, 2010  I understand that this event will take place away from the parish grounds and that my son/daughter will be under the supervision of authorized parish personnel (as indicated above) on the stated dates.  I consent to the stated conditions for participation in this event, including the method of transportation.  I further understand that if my child chooses behavior that is inappropriate, I may be requested to remove my student from the program and pick them up at the event.

______________________________________________   ________________________________________________  _______________

(print parent’s name)                                                          ***************Parent’s Signature******************   (date)

_____________________________________________   _______________________  ______ __________ _______________________

Address                                                                                    City                                      State      Zip               Phone

Medical Information

My child is allergic to:_____________________________________________________________________________________________

My child must take the following medication (indicate dosage, frequency, etc.):

_______________________________________________________________________________________________________________

Please note specific medical problems (use back if necessary):______________________________________________________________

In case of emergency notify : Name___________________________________________________ Phone__________________________

If the above person is not available notify: Name_________________________________________Phone__________________________

I grant permission for non-prescriptive medication (e.g. Tylenol, throat lozenges, cough syrup, pepto-bismol, etc.); and routine non-surgical medical care to be given to my child if deemed advisable by the supervising parish/school personnel.   In case of emergency, I also grant permission to transport my child to the nearest hospital for emergency medical treatment.  I will be contacted as soon as possible and will be advised prior to any further treatment by the hospital or doctor. 

****Parent’s Signature****________________________________________________________   Date__________________________

Family Health Plan _______________________________ Health Plan Number_____________________________ Exp. Date_________

Parents: Please check below if you are able to drive youth to this event.  You will be contacted in advance if drivers are needed for this event.

____I can drive to this event.    My vehicle can seat______(number of youth).  Your Phone Number______________________________

A medical release form must be on file before your son/daughter may participate in this activity.