St. Margaret Mary Catholic Church Youth Ministry

Coalition for the Homeless 2008/2009

2008 (M/S) Mondays: July 14; August 11; September 8; October 13; November 10; December 8

(H/S) Wednesdays: July 9; August 13; September 10; October 8; November 12; December 10

2009 (M/S) Mondays: January 12; February 9; March 9; April 13; May 11; June 8; July 13

(H/S) Wednesdays: January 14; February 11; March 11; April 8; May 13; June 10; July 8

**M/S = Middle School (Grades 6-8) **H/S = High School (Grades 9-12)

Participant’s Name: __________________________________________________

Address: ___________________________________________________________

City, Zip: _____________________________ Date of Birth: _________________

Grade (Fall 2008): ____________ School Attending: ________________________

Phone #: ( ) Email: ____________________________

Parent/Guardian: _____________________________________________________

Address (if different from above): _______________________________________

Phone #: ( ) Email: _____________________________

Work Phone #: ( ) Cell #: (_____)____________________

*Emergency Contact in the event a parent cannot be reached:

Name: _____________________________________________________________

Address, City, State, Zip: ______________________________________________

Relationship: ________________________________________________________

Phone #: ( ) Cell #: (_____)____________________

Permission and Release

The undersigned, who is the parent/legal guardian of ________________________________ a minor (hereinafter referred to as “Participant”), on behalf of himself and Participant, their personal representatives, assigns, heirs and next of kin, request Participant be permitted to participate in the aforementioned event.

1. Hereby releases, waives, discharges and covenants not to sue St. Margaret Mary Catholic Church, the Diocese of Orlando, their officers, employees and agents, all for purposes herein referred to as Releases, from all liability to the undersigned and Participant, their personal representatives, assigns, heirs and next of kin, for all loss or damage, and/or claims demands, causes of action or suites of any kind therefore, particularly on account of injury to the person or property or resulting in the death of the Participant, whether caused by the negligence of Releases or otherwise, while Participant is involved in the aforementioned event;
2. Hereby agrees to indemnify and save and hold harmless the Releases and each of them from any loss, liability, damage, or cost they may incur while Participant is involved in the aforementioned event, whether caused by the negligence of Releases or otherwise;
3. Hereby assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of Releases or otherwise while Participant is involved in the aforementioned event;
4. Hereby agrees that if any portion of the Agreement is held invalid, that the balance shall, notwithstanding, continue in full legal force and effect.

Signature of

Parent/Guardian: ________________________________________ Date: __________________

Medical Release/Information

In the event Participant becomes ill or injured, I authorize the directors or any of the parish chaperones to obtain medical attention at a physician’s office, hospital, by an EMT or other emergency medical services. I understand that every effort will be made to reach me before medical permission is given to treat my child. The participant is covered by the following medical insurance:

Insurance Company: _____________________________________________

Policy #: __________________________ Group #: ______________________

Allergies (list):

Current Medications (list):

Chronic/Acute Illnesses:

Other Important Medical Information:

Signature of

Parent/Guardian: ________________________________________ Date: __________________