ARCHDIOCESE OF BALTIMORE

DIVISION OF YOUTH & YOUNG ADULT

MINISTRY

PERMISSION FORM AND RELEASE

Youth Name: Home Phone:

Parent Name: Work Phone:

Other number where Parent can be reached: _____________________________________

Address City/State/Zip

Date of Birth:_____________________________ Male Female (please circle)

In consideration of the wholesome recreational experience in which my son/daughter will participate, I as parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to attend the youth ministry/campus ministry group of their parish at: __________________________

________________________________________________________________________________

I/we acknowledge receipt of the attached information sheet describing the planned activities.

In consideration of the opportunity for my son/daughter to participate in the Program, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY St. Ignatius of Loyola Church and the Division of Youth & Young Adult Ministry, the Roman Catholic Bishop of Baltimore and his successors, a Corporate Sole, and all their agents, servants and employees from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my son/daughter’s participation in the Program.

I hereby grant permission to ____________________to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached. (Check one of the following:)

❐ I am covered by hospitalization and medical insurance under policy #__________________issued by .

❐ I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my son/daughter.

ADD any dietary restrictions: ______

Date: _______________ Parent Signature ______________________________