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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 employees from Our Lady of Grace Parish.  A brief description of the activity follows:

Name of Event: 2018 Summer Mission Trip to Young People Who Care, Inc.

Who: Open to all teens and young adults 16-20 years of age

Destination:  Young People Who Care, INC.  Frenchville PA

Designated Supervisor of Activity: Katrina Coleman 412.592.5406
                                                    
Date and Time of Start: Sunday June 15, 2018 @ 2:00 pm from OLG

Date and Anticipated Time Completion: Friday June 20, 2018 @ 2pm

Method of Transportation: rental van arranged by the Youth Ministry

Student Cost: $100

Other:  There are other forms to be completed for the mission center. Please contact Katrina for these forms

 

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

I hereby consent to participation by my child in the event described above.We, the parents/guardians do hereby give our permission for him/her to attend  I understand that this event will take place away from the school/parish grounds and that my child will be under the supervision of the designated school/parish employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.

We do hereby release and forever discharge the Diocese of Greensburg and designated chaperones from any/all actions or suits in law or equity which we might hereafter have by reasons of injuries sustained by our son/daughter participating in the above mentioned activity.  In case of emergency, we give permission for our child to be treated at a hospital and/or by a medical doctor.

PHOTOGRAPHIC RELEASE LETTER

I hereby grant to the Diocese of Greensburg, Pennsylvania, and its respective licensees, successors and assigns, the right and permission, with respect to those photographs taken of me or the minor named below on whose behalf I am signing, and with respect to any printed or electronic matter in connection therewith, to do the following: To include such photographs on the Diocese of Greensburg website and on print material (names of minors are not used for web or print media/publications without prior consent)

I hereby release, discharge and agree to indemnify and hold harmless the Diocese of Greensburg and its legal representatives, licensees, successor and assigns, from all claims and demands whatsoever arising out of or in connection with the foregoing, and waive any right to inspect or approve the same.

I hereby certify that I am the parent and/or guardian of a minor under the age of eighteen years, and hereby consent on behalf of said minor to the use of any of the photographs taken of said minor pursuant to the terms set forth in this Photographic Release, including, without limitation, the release, discharge and hold harmless provisions thereof.

Date: May 27, 2018

Please select who will be participating...
Minor
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First Teen's Name

First Name*

Middle Name

Last Name*

Phone*
First Teen's Date of Birth*
First Teen's Information
Grade Level for Fall 2018-19*

Teen's Cell Phone
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions
Can this person be given the following by the medical coordinator? (please check all)
Iburprofen
Acetaminophen
Benedryl
Pepto Bismal
Immodium
First Teen's Signature*
Teen's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Grade Level for Fall 2018-19*

Teen's Cell Phone
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions
Can this person be given the following by the medical coordinator? (please check all)
Iburprofen
Acetaminophen
Benedryl
Pepto Bismal
Immodium
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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